EPA TCTAC ICR_Instruments - Intake Surveys

Intake Surveys

Center	Page Number
Center A	2 – 4
Center B	5 – 8
Center C – General 1	9
Center C – General 2	10 – 15
Center C - Events	16
Center D	17 – 18
Center E	19 – 20
Center F	21 – 22
Center H	23 – 26
Center J	27 – 28
Center K	29 – 30
Center L	31 – 32
Center M – Version 1	33 – 36
Center M – Version 2	37 – 43
Center N	44 – 46
Center O	47 – 51
Center P	52 – 54

Intake Survey
Center A

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 30 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

Organization Name:
Address:
How did you hear about the Center A?	DSCEJ staff, website, or newsletter  Social Media  Online Search  Press Release/Media Coverage  Email  EPA or other federal agency  Referred by another Center (specify)  Referred by another organization (specify)  Referred by another individual (specify_)  Other (specify)
Personnel
Organization Leader Name:
Race and Ethnicity of Organizational Leader:	Select all that apply:  Black/African American  White  Asian  American Indian/Alaska Native  Native Hawaiian or other Pacific Islander  Latino/Hispanic
Gender of Organizational Leader:	Man  Woman  Non-Binary  Prefer to Self-Identify: ________
Organization Leader Email
Organization Leader Phone
Assistant Name
Assistant Email
Assistant Phone
Organizational Information
Website and Social Media
Mission Statement
Organizational Status	501c3  Faith-based  Other: _________
Do you have a fiscal sponsor?	Yes  No
Number of Full Time Employees:
Number of Part Time Employees:
Number of Volunteer Workers:
Does the organization have a physical space? (office, community center, home-based)	Yes  No
Is there dedicated space for community meetings and events?	Yes  No
Does the organization have a computer or laptop?	Yes  No
Does the organization have a reliable wifi connection available?	Yes  No
Does your organization have a board that meets regularly?	Yes  No
What is your annual budget?
What are your funding sources (present)?	Check all that apply:  Federal  State  Local  Foundation  Donor
Community Information
Communities and Neighborhoods your organization serves:
Do any of the communities you serve fit into any of the following categories?	Check all that apply  Community of color  Low-income community  Indigenous community  Rural community
Issues faced in these communities:
Demographics of Communities Served by Organization
Briefly describe your organizational priority issues
Select one or more of the categories of funding that you have identified as a priority for your community:	Check all that apply:  Climate Change  Clean Energy and Energy Efficiency  Clean Transit  Affordable and Sustainable Housing  Training and Workforce Development  Remediation and Reduction of Legacy Pollution  Development of Critical Clean Water and Wastewater Infrastructure
Our technical assistance offerings fall into these general categories - please select the areas in which you are most interest in accessing technical assistance	Check all that apply  Organizational Development (building your organizational structure, leadership, and board; member recruitment and outreach)  Identifying Issues and Prioritizing Needed Change (convening community members to identify priority environmental and energy justice issues)  Building Organizational Capacity to Pursue Needed Change (building knowledge and skills in environmental and energy justice; developing research skills to access, collect, and analyze data)  Making the Case for Change (GIS mapping, community profile development; storytelling)  Building Relationships (engaging partners, including peers, local, state, and federal decision makers, regulatory agencies, etc.)  Grant Writing, Research, Submission, and Management Skills (building skills to identify and access grant opportunities; write and submit competitive applications; and managing awarded grants)

Intake Survey
Center B

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 10-15 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

 

Center B is a 501c3 nonprofit organization that provides pro bono capacity-building technical assistance to disadvantaged communities, nonprofit organizations, and under-resourced state/local/Tribal government entities. We have a volunteer network of over 550+ EPA alumni as well as staff who are fully dedicated to this work across the country.  

 

If you are interested in receiving assistance on some aspect of either the Environmental Justice Collaborative Problem-Solving (EJCPS) Cooperative Agreement Program or the Environmental Justice Government-to-Government (EJG2G) Program applications, please fill out this survey and someone from Center B or one of our partner organizations will get back to you. If you have filled out a different survey from Center B in the past, please also fill this one out.  

 

If you have any questions or would like to provide pro bono assistance, please contact us at [email here]. 

 

1. Email 
   
   

2. Name 
   
   

3. Organization 
   
   

4. Does your organization have: Mark only one oval 

• 501(c)(3) tax status 

• Community-led organization that does not have 501(c)(3) tax status 
   

5. Are you interested in the EJCPS, EJG2G, both, or unsure? Mark only one oval 

• EJCPS 

• EJG2G 

• Both 

• Unsure 
   
  
  

6. What EPA region are you located in? You can choose more than one. Check all that apply. 

• Region 1 (CT, ME, MA, NH, RI, VT, and 10 Tribal Nations 

• Region 2 (NJ, NY, Puerto Rico, the U.S. Virgin Islands, and 8 Indian Nations) 

• Region 3 (DE, DC, MD, PA, VA, WV, and 7 Federally Recognized Tribes) 

• Region 4 (AL, FL, GA, KY, MS, NC, SC, NT, and 6 Tribes) 

• Region 5 (IL, IN, MI, MN, OH, WI, and 35 Tribes) 

• Region 6 (AR, LA, NM, OK, TX, and 66 Tribal Nations) 

• Region 7 (IA, KS, MO, NE, and 9 Tribal Nations) 

• Region 8 (CO, MT, ND, SD, UT, WY, and 28 Tribal Nations) 

• Region 9 (AZ, CA, HI, NV, the Pacific Islands, and 148 Tribal Nations) 

• Region 10 (AK, ID, OR, WA, and 271 Tribal Nations) 

• We’re a national organization 

• Unsure 

• Other 
   

7. Have you registered with Grants.gov and SAM.gov and gotten your Unique Entity ID (UEI) number? Please note that an EIN is NOT the same as a UEI. Check all that apply. 

• Yes, I have registered with Grants.gov 

• No, I have not registered with Grants.gov 

• Yes, I have registered with SAM.gov 

• No, I have not registered with SAM.gov 

• Yes, I have received a Unique Entity ID (UEI) number. 

• No, I have not received a Unique Entity ID (UEI) number. 

• Unsure 
   

8. Would you like assistance with any of the above-mentioned programs? Mark only one oval. 

• Yes 

• No 

• Maybe 
   

9. Do you have a grant writer or funding for a grant writer for this application? Mark only one oval. 

• Yes 

• No 

• Maybe 
   

10. Do you have staff or volunteers (in addition to the grant writer) who can dedicate time to this application? Mark only one oval 

• Yes 

• No 

• Maybe 

 

11. For the relevant funding opportunities that you are interested in, have you participated in or watched an EPA webinar and reviewed the slides? 

EJCPS Grant:  

• Recording of the January 24, 2023, EJCPS webinar  

• Passcode: 85564988  

• Slides from the January 24, 2023, EJCPS webinar (pdf)  

EJG2G Grant:  

• Recording of the January 26, 2023, EJG2G webinar  

• Passcode: 42015614  

• Slides from the January 26, 2023, EJG2G webinar (pdf)  

Mark only one oval 

• Yes 

• No 
  
  

12. Have you read the overview and at least skimmed the Request for Applications for the relevant funding opportunities? 

EJCPS Grant:  

• Summary of the EJCPS Coop. Agreement Program  

• EJCPS Request for Applications  

EJG2G Grant:  

• Summary of the EJG2G Program EJG2G  

• Request for Applications  

Mark only one oval 

• Yes 

• No 

 

13. Recognizing the requirement and/or preference for applications with partnerships, have you filled out the EPA Partner Survey and/or the EJG2G Partner Survey for the relevant funding opportunities that you are interested in? If not, please try to take a moment to do so now. It does not take long. Mark only one oval. 

• Yes 

• No 
   

14. Have you reviewed the relevant lists of organizations looking for partners (EJCPS potential partners or the EJG2G potential partners) and reached out to potential partners on these lists or elsewhere? Mark only one oval. 

• Yes 

• No 
   

15. If you have identified potential partners, please list their names, organizations, and contact information below. Write N/A if you have not identified partners yet. [text box] 
     

16. Select one or more of the options below to best describe your community or the community or entity you represent. Check all that apply. 

• Low-income community 

• Community of color 

• Disadvantaged community 

• State government 

• Local government 

• Tribal government 

• Other government 

• None of the above 

• Other 

 

17. Are you a member of the Anthropocene Alliance? Are you currently or were you previously part of an AGU Thriving Earth Exchange or Justice40 Accelerator cohort? Check all that apply. 

• Anthropocene Alliance member 

• AGU Thriving Earth Exchange (current or previous cohort) 

• Justice40 Accelerator (current or previous cohort) 

• None of the above 
   

18. Have you received a federal grant or had a cooperative agreement with a federal agency?
    Mark only one oval. 

• Yes 

• No 

 

19. After completing the questions above, are you still interested and committed to receiving assistance on submitting an application? Mark only one oval. 

• Yes 

• No 

 

20. Is there anything else that you would like to share? [text box] 

Initial Intake Survey 

Center C 

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 2 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

 

 

Contact Us 

 

Center C is looking forward to providing technical assistance (TA) for communities and families in our region. We'd like to work with you to address TA needs across the [Region]. Please share your information below, so we can make sure to reach out to you as we ramp up our activities and offerings over the coming months.
  

(Items marked with an * require a response in order to submit the form) 

1. Full Name (First Name, Last Name)* 

2. Email address* 

3. Organization Name * 

4. Phone number 

5. State [List of states in region for single select]* 

6. City* 

7. Zip code* 

8. How can we help you? [Open text] 

General Intake Survey 

Center C 

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 8 to 15 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

 

 

Topic	Questions
Contact Information	Are you completing this survey representing an organization or as an individual?   Organization (or other type of institution)  Individual (or for my community)    Your Information:  Name (required)*_______  [Organizations only] Position in organization _______  [Organizations only] Years with organization _______  Email (required) _______  Phone number _______    [Organizations only] Organization Name*   [Organizations only] Organization’s website  [Organizations only] Are you the primary point of contact for your organization?  Yes  No    [if “no” response to previous question] [Organizations only] Primary Point of Contact (required)*:   Name _______  Position in organization _______  Years with organization _______  Email (required) _______  Phone number_______    [Organizations only] Alternate contacts (optional) [include 2 spots for alternate contacts in form]:   Name _______   Position in organization _______  Years with organization _______    [Show instruction text for organizations only] Address of your organization:  [Show instruction text for individuals only] Your home address:    Street Address (optional)  City (optional)  State* (required)  Zip Code* (required)    Additional contact information (if needed) [Text Box]:
Location and Funding	[Show instruction text for organizations only] For the rest of the questions, if asked about “your organization/you”, please answer on behalf of your organization, not you personally.  [Show instruction text for individuals only] For the rest of the questions, if asked about “your organization/you”, please answer on behalf of yourself/your community. (You should not answer about an organization.)    Which best describes where [your organization is/you are] located?  City or urban community  Suburban community  Rural community (select town size)  Other [Describe]     [IF NOTED AS A RURAL COMMUNITY]: What best describes the size of your town?   Has less than 10,000 people  Has more than 10,000 people  Don’t know    [Is your organization/Are you] located by current or former mine land?   Yes  No  Don’t Know    [Organizations only] Does your organization have 501c3 nonprofit status?  Yes  No  Don’t Know    [Organizations only] What is your organization’s annual budget?  Under $1,000  $1,001-$250,000  $250,001-$500,000  $500,001 - $1Million  Over $1 Million  Don’t Know    [Organizations only] How many paid full time and part time staff does your organization employ?  # Full time___  # Part time___  Don’t Know    [Organizations only] Has your organization ever applied for funds from the US Environmental Protection Agency (EPA) or US Department of Energy (DOE)?   Yes  No  Don’t Know    [Organizations only] Has your organization ever received/been awarded funds from the EPA or DOE?   Yes  No  Don’t Know
Underserved Communities	[Organizations only] Does your organization currently work with any of the following groups? [Select all that apply]  Racial and ethnic communities that have been disproportionately impacted by environmental justice issues. (Please Describe): Text Box  People or households with incomes below the federal poverty level  Indigenous or tribal groups  Rural communities   People experiencing homelessness
Environmental Justice Issues	What environmental justice issues [is your organization/are you] currently working on or want to address?* [Select all that apply]  Solid/hazardous waste disposal [Describe] Optional Text Box  Air [Describe] Optional Text Box  Water/drinking water [Describe] Optional Text Box  Soil [Describe] Optional Text Box  Personal exposure analysis [Describe] Optional Text Box  Climate change resilience [Describe] Optional Text Box  Food waste/scarcity [Describe] Optional Text Box  Housing [Describe] Optional Text Box  Energy justice [Describe] Optional Text Box  Other [Describe] Optional Text Box
Capacity	[Organizations only] How would you rate your organization’s capacity to prepare a federal grant application (such as submitting a funding application to the US EPA or DOE)?  By capacity we mean having leadership, infrastructure, staff, knowledge, funding, and partnerships to successfully complete the application process.  Strong capacity (Our organization has the leadership, systems/infrastructure, staff, skills, financial resources, and partnerships to prepare an application)    Moderate capacity (Our organization is knowledgeable about grant writing and can prepare a successful grant but faces challenges in developing the application or budget/management systems.)  Basic capacity (Our organization knows about grants and sometimes submits applications but lacks procedures or sufficient support to do so regularly.)  Low capacity (Our organization does not have the resources to apply for grants.)    To what extent do you agree or disagree with the following statement? I understand what environmental or energy justice grants are available to [my organization/me].  Strongly agree  Somewhat agree  Somewhat disagree  Strongly disagree    To what extent do you agree or disagree with the following statement? I’m confident I can help fix the environmental challenges in my community.   Strongly agree  Somewhat agree  Somewhat disagree  Strongly disagree
Technical Assistance needs	What types of technical assistance are you interested in? (Select all that apply)*  Identifying and navigating funding sources to apply for (federal, local, private)   Grant writing for environmental and energy justice (EEJ) related funding   Navigating government funding systems such as SAM.gov and Grants.gov  Managing federal grants (e.g., accounting, financial policies, spending controls)  Developing partnerships and coalitions addressing environmental and energy justice (EEJ)  Engaging/educating community  Assisting community stakeholders to participate in environmental and energy justice decision making  Using web-based tools (e.g., EJ Screen, CEJ Screening Tool)   Applying for 501c3 status  Providing language services (e.g., translation and interpretation services with respect to environmental and energy justice challenges)  Consulting with technical (e.g., scientific) experts for an environmental justice issue  Connecting with university faculty/students  Data needs  Workforce development  Administrative (accounting)  Other [Describe] Text Box
Delivery of Technical Assistance	Please rank from 1-8 what formats of technical assistance interest you most?*   In-person training  Virtual training  One-on-one consultation  Peer-to-peer networking/learning sessions   Toolkits and Tip Sheets  Listserv  Student assistance/practicum  Other [Describe] Text Box  Don’t know – depends on topic
Top priority for Center C	The purpose of Center C is to support environmental justice efforts of communities that are underserved to improve human and environmental health outcomes in the [region].     How can Center C best support [your organization/you] in achieving [its/your] environmental justice goals?  [Describe] Text Box
Communication	What is the best way to communicate with you?*  Email  Phone call  Text message  Other [Describe] Text Box    Do you have challenges with broadband and internet access?*  Yes [Describe] Text Box  No    What is your preferred language for communication?* [Describe] Text Box    Center C OPT OUT: Please check here if you do not want to be included on our contact list for announcements of upcoming technical assistance activities, resources, and funding opportunities.     [organization] OPT OUT: Center C is working with the [organization] to support communities and individuals working for environmental justice in EPA Region X. Please select this box if you do NOT want your contact information shared with the [organization] to help build this network.
Areas of expertise	What knowledge and experience [does your organization/do you] have that could help others in their environmental justice efforts?  Identifying and navigating funding sources to apply for (federal, local, private)   Grant writing for environmental and energy justice (EEJ) related funding   Navigating government funding systems such as SAM.gov and Grants.gov  Managing federal grants (e.g., accounting, financial policies, spending controls)  Developing partnerships and coalitions addressing environmental and energy justice (EEJ)  Engaging/educating community  Assisting community stakeholders to participate in environmental and energy justice decision-making.  Using web-based tools (e.g., EJ Screen, CEJ Screening Tool)   Applying for 501c3 status  Providing language services (e.g., translation and interpretation services with respect to environmental and energy justice challenges)  Consulting with technical (e.g., scientific) experts for an environmental justice issue  Connecting with university faculty/students  Using data  Workforce development  Administrative (accounting)  Other [Describe] Text Box    [Organizations only] Center C is building a resource hub of existing environmental justice resources to share with organization across the network. What resources (e.g., fact sheets, training videos, social media templates, marketing material) has your organization developed that you would be willing to share with others?  [Text box]
Hear about Center C	How did you hear about Center C?* Via…  Email/listserv  Website  Newsletter/blog  EPA/other government agency  Partner organization  Network  Other [Describe] Text Box

Intake Survey - Events

Center C 

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 2 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

 

Sign-in Sheet 

 

Thank you for attending our event. 

Please complete the following information so we know who was here. 

 

1. Event name (autofill) 
   
   

2. Event date (autofill) 
   
   

3. First and Last name(s)* 
   
   

4. Organization (If you represent an organization) 
   
   

5. Zip code* (For your organization. If not applicable, put your home zip code) 
   
   

6. Email address (by providing an email address and/or phone number, you agree to being contacted by [CENTER] staff about activities regarding environmental justice in the [EPA region] 

If you do not have an email address, please check this box: [I do not have an email address] 

[If prior box checked, a field will appear asking for phone number (not required)] 

7. Do you give permission for the Center C team or EPA to use photos or videos of you from this event in materials for the public?* .  

Yes/No 
(By writing “yes” for photo consent, you are allowing the Center C team and the U.S. Environmental Protection Agency (EPA) to use photos or videos of you from this event in materials for the public.) 

 

* = required 

Intake Survey 

Center D

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be between five and ten minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

  

Instructions: The information in this form will help us provide timely and effective support. Please answer as many questions and provide as much information as you can at this time.  

 

1. Contact Name  

2. Email address  

3. Phone number  

4. What is your preferred method of contact?  

1. Phone  

2. Email 

3. Either is fine   

5. Position or title 
   
   

6. Organization name 

7. Organization street address 

8. Organization city 

9. Organization state/territory/nation 

10. Organization zip code 

11. Which of the following best describes your organization?  

1. Nonprofit organization 

2. Community-based/grassroots organization (I.e., not a nonprofit) 

3. Philanthropic and civic organization 

4. Faith-based organization 

5. Educational institution (e.g., school district, college) 

6. Private Business 

7. Local government 

8. State government 

9. Tribal government 

10. US territory 

11. Individual 

12. Other, please specify: __________________ 
     

12. Organization website or social media (if applicable) 
     

13. Is your organization affiliated with a tribal nation (federally or not federally recognized)?  

1. Yes
   If yes, which one? ______________________ 

2. No 
    

14. Tell us about the community or area you serve or work in. 
    
    

1. What do you want us to know about the community or area?
   Please provide a brief description. 
   
   

2. Service area name (e.g., XX neighborhood) 
   
   

3. Service area location (e.g., town/city, county, zip code, neighborhood, state) 
   
   

4. Is this an underserved community? (Note: an underserved community includes any population sharing a particular characteristic that has been systematically denied a full opportunity to participate in aspects of economic, social or civic life. Examples include but are not limited to: Black Latino, Indigenous and Native American, other persons of color, members of religious minorities, LGBTQ+ communities, persons with disabilities, persons in rural communities', persons impacted by persistent poverty.)  

1. Yes, ii. No, iii. Not sure
   
   

5. Is this community or area located on current or former mining land? 

1. Yes, ii. No, iii. Not sure
   
   

6. Is this community or area in a remote or rural area? 

1. Yes, ii. No, iii. Not sure

15. Please provide a general description of the issue and what assistance you are looking for. 
     

16. What forms of support have you received regarding this issue in the past (technical assistance, federal funding, testing, research, etc.), if any?  
     

17. Is there anything else you would like us to know?  
     

18. How did you hear about us?  

1. Email 

2. Event (in-person or virtual) 

3. Family/friend/colleague 

4. Printed material (e.g., flyer, postcard) 

5. Search engine (e.g., Google) 

6. Social media (e.g., Facebook, Instagram) 

7. Website 

8. Organization/group 

9. Other: __________ 

Intake Survey
Center E

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be between 30 and 45 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

 

Organization Name:  ___________________________________________________________________________________________ 

Location:  ________________________________________________________________________________________

Contact Person & Email: ______________________________________________________________________

Organization Website: ________________________________________________________________________

 

Please check the service(s) that best applies to your inquiry: 

 

____ Grant Seeking & Writing   
____ Community Engagement Assistance  
____ Capacity Building 
____ Project Implementation

____ Energy Justice  

____ Sustainable Square Mile Replication  

 

QUESTION	RESPONSE
1.  What challenges or problems are you seeking to address?   (Please provide a detailed description.)
2.  What do you currently have in place for your target areas of concern?   What previous actions were taken to address your concerns?
3.  What are your top priorities/goals?   (Please list regarding to importance.)
4.  What does a successful outcome look like to you?
5.  What budget/financial constraints do you need to work within?  What experiences do you have with applying for and managing government grants?  Are you registered with Grants.gov?     Are you registered with Sam.gov?
6. Are there any specific deadlines or timeframes that should be adhered to?
7. Please expound on your current organization/staff  capacity and needs.      Who are the key decision-makers for your organization?  (Please include names, email addresses, and telephone numbers.)
8.  Additional Information –  (Please add any additional information that may be pertinent for our team to make the best and informed decision(s)regarding your inquiry.)

Intake Survey 

Center F 

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 5-10 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

  

General information 

Organization Name:

Organization Type:

Physical Address: 

Municipality/County:

Zip Code: 

Main Point of Contact:  

First Name: 

Last Name: 

Position and Title: 

Email:
Please enter your preferred email that is checked regularly. This is our primary form of communication.

Telephone:

Organization Information: 

Date of Incorporation of the Organization: 

Mission of the Organization:

Your organization main activities: 

1. Environmental: 

2. Energy:

How did you learn about this Technical Assistance Center? 

• Referred by TA Provider 

• EPA/DOE Website 

• Center Website/Newsletter 

• TA Provider Website  

• Social Media (LinkedIn, Facebook, Instagram, Twitter) 

• News/ Press Release Article 

• Other 
  
  

Project Details

Please provide details on the technical assistance you are requesting, including specific questions (e.g. sam.gov registration, grants.gov registration and grant opportunities, eligibility, grant writing/review, feasibility study, other requirements, etc.) The more details you can provide, the quicker we can connect you to our TA network. 

1. Collaborative Problem-Solving Model 7 steps used by EPA (Issue Identification, Strategic Goals, Community Capacity Building and Leadership) 

2. Business Canvas Boot Camp (Identity, Mission, Vision, SWOT) 

3. Environmental Justice and Advocacy (Effectively engage with stakeholders) 

4. Energy Justice and Advocacy (Energy Project Design and Implementation) 

5. Grant writing and grantsmanship (Training in competitive proposal writing 

6. Technical Assistance in funding opportunities 

7. Technical Assistance in grant submission (SAM.gov or Grants.gov) 

I understand that the Center F program does not offer or provide contractor services or financial capital. It does not offer grant writing or project management services, nor does your voluntary use of Center F materials guarantee the success of a grant application or the grant funding for your project.*

 

Intake Survey

Center H

 

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 5-15 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

Center H is committed to offering technical assistance to build thriving communities. Please complete the form below to help us understand what type of technical assistance you’re seeking or call us at xxx.

 

Accessibility 

If you have any specific needs or requests, including the translation of this form into a language other than English or accommodations for disabilities such as sign language interpretation, braille materials, or assistance with reading the form and filling it out on your behalf, please or call (971) 341-3859. 
 

Privacy 

Your personal data will be kept confidential and reported in aggregate form to the Environmental Protection Agency (EPA) and the Department of Energy (DOE) as a requirement for the grant we received for Center H. 

Your information 

• Name 

• Title 

• Your organization/business name or community affiliation (write N/A if not applicable) 

• Please select the group(s) that you identify with (Select all that apply): 

• Asian  

• Black or African American 

• Elder persons (i.e., 65 years and older) 

• Hispanic or Latino/Latina/Latinx 

• Houseless persons 

• Immigrants 

• Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons 

• Low-income persons 

• Middle Eastern or North African 

• Mesoamerican Indigenous 

• Native Hawaiian and Pacific Islanders 

• Native American/Indigenous/American Indian/Alaska Native 

• Persons who live in rural or remote areas 

• Persons with disabilities 

• Refugees  

• Religious minorities 

• Other, please specify 
  
  

• Website of your organization/business (if applicable) 
  
  

• Which of the following best describes your business/organization? (Select all that apply) 

• Community based or grassroots organization 

• Nonprofit organization 

• Philanthropic 

• Tribal Government or Intertribal Consortia 

• Native American Organization (includes nonprofits, cooperatives, corporations, partnerships) 

• Local Governments (as defined by 2 CFR 200.1 – includes cities, towns, municipalities, and counties, public housing authorities and councils of government) 

• Institutions of higher education (e.g., private and public universities and colleges, including community colleges) 

• Private business  

• Special district 

• Don't know/Not sure 

• Other (please specify) 

• Preferred form of contact  

• Email  

• Phone call 

• SMS/text messaging  
  
  

If previous response = Email: Please provide your E-mail address for future communications [Open ended] 

If previous response = Phone or SMS/text:  Please provide your phone number for future communications [Open ended] 

• What is your preferred language for future communications? [Open ended] 

 

Community information 

Please provide the following socio-demographic information for the impacted community or communities for which you are seeking technical assistance. 

• Name of the community [Open ended]  

• Which state is this community located in? [Open ended within region]  
  
  

• Please select the group(s) that represent the impacted community or communities. (Select all that apply)  

• Asian  

• Black or African American 

• Elder persons (i.e., 65 years and older) 

• Hispanic or Latino/Latina/Latinx 

• Houseless persons 

• Immigrants 

• Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons 

• Low-income persons 

• Middle Eastern or North African 

• Mesoamerican Indigenous 

• Native Hawaiian and Pacific Islanders 

• Native American/Indigenous/American Indian/Alaska Native 

• Persons who live in rural or remote areas 

• Persons with disabilities 

• Refugees  

• Religious minorities 

• Other, please specify 

• Please use this space if you would like to provide more details about the group(s) that represent the impacted community or communities. (e.g., Thai community in eastern area of a state). [Open ended] 

 

• What is the approximate population of the impacted community? 

• 2,500 or under 

• 2,500 to 10,000 

• 10,000 to 50,000 

• More than 50,000 

• I am not sure 
  
  

• What is the preferred communication language of the impacted community?  

• English 

• Spanish or Spanish Creole 

• Chinese (including Mandarin and Cantonese) 

• Vietnamese 

• Russian 

• Korean 

• Tagalog 

• Indigenous Native languages (e.g. Yup'ik, Inupiaq, etc.) 

• Arabic 

• Other, please specify 

Environmental or Energy Justice Issue 

• Please provide a brief description of the energy or environmental justice issue faced by the community you are submitting this request on behalf of. [Open ended]  

• What kind of Technical Assistance can Center H provide to support you or the community you are submitting this request on behalf of? If you’re not sure, that’s ok, we will follow up with you to discuss further. [Open ended]  

• Please describe any previous actions taken by you or other individuals or groups to address the issue. [Open ended]  

• What is the preferred timeline for this Technical Assistance request? [Open ended] 

 

Final section 

• How did you hear about Center H? [Open ended]  

• Would you like to be added to the Center H email list and newsletter? [yes/no]

Intake Survey 
Center J

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 5-8 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

  

Welcome to the Center J Technical Assistance Collaborative intake form. 

 

The Center J TCTAC aims to service underserved, rural, and remote communities impacted by environmental injustice within two states and eight Tribal Nations. 

 

Our overall goal is to build power and knowledge in environmental justice (EJ) communities, create or strengthen EJ networks within our region, and help groups gain access to grant and funding opportunities so that they're better positioned to advance and address environmental and energy justice issues. 

 

If you are interested in receiving assistance, please fill out this short intake survey and our team will follow up to schedule an introductory call. 

 

1. First and Last Name: 

 

2. Email Address: 

 

3. Where are you located (City, State, Zip Code)? 

 

4. Organization Type (select all that apply)

• Nonprofit organizations 

• Community-based and grassroots organizations 

• Philanthropic and civic organizations 

• Underserved communities and organizations 

• Rural and Remote communities and organizations 

• Faith-based organizations and churches 

• Educational institutions (e.g., schools, colleges, and universities), including Minority Serving Institutions 

• Individuals from underserved communities 

• Disadvantaged Businesses 

• Local, tribal, and state governmental units 

• US Territories 

• Utility providers 

• Healthcare providers and clinics 

 

5. Organization/Institution Name (if applicable)? 

 

6. Tell us more about the communities that your organization/institution serves – where are they located within Center J’s region? 
    

7. Describe the problem you hope to address, the type of project you'd like to develop, or the funding opportunity you'd like to apply for. 

 

8. What type(s) of technical assistance (TA) are you seeking (select all that apply)? 

• Federal grant registration and eligibility 

• Federal grant writing assistance 

• TA for other types of grants 

• TA for identifying EJ issues 

• TA for designing projects to address community EJ issues 

• Clean energy or energy justice assistance 

• Partnership development 

• Grants management post-award 

• Other [text box] 

 

9. How would you rate your group's capacity to apply to grants (select one)? 

• Don’t even know where to begin 

• Slightly confident in our ability to apply 

• Somewhat confident in our ability to apply 

• Moderately confident in our ability to apply 

• Extremely confident in our ability to apply 

 

10. How did you learn about our technical assistance center (select all that apply)? 

• Center J Website/Newsletter 

• TCTAC Presentation/Training 

• TA Provider or Partner Org 

• EPA/DOE or other Federal or State Agency 

• Elected Official 

• Other [text box] 

 

Intake Survey 
Center K

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be under 8 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

1. Name 

2. Phone Number  

3. Email  
   
   

4. Do you represent a Tribe, Tribal organization, or Inter Tribal consortium? Please identify. 

1. Tribe 

2. Tribal Organization 

3. Inter-Tribal Consortium 

4. Other 
   
   

5. In what state is your community located? If your Tribal boundaries are in more than one state, select the state your headquarters are in. 
   
   

6. Please describe the environmental, climate justice or clean energy concern you would like to address. 
   
   

7. What type of technical assistance are you seeking? 

1. Search for appropriate/relevant federal funding 

2. Federal funding application assistance 

3. GIS Mapping Services* 

4. Resources and Information 

5. Other  
   
   

*If GIS Mapping Services is selected, these questions will populate:  

 

 Type of GIS Assistance  

1. Technical Assistance with GIS Software Assistance with Locating Geospatial Data  

2. Assistance Creating Maps and Story Maps  

3. Other Geospatial Assistance  

If 1:   

1a. GIS Software – please chose the software your inquiry is regarding.  

• ArcGIS Pro  

• ArcGIS Online  

• ArcMap  

• Portal for ArcGIS  

• Survey123  

• Field Maps  

• Story Maps  

• Dashboards  

• Other   

1b. GIS Software Version  

If 2:   

2a. Describe the data you are looking for. 

If 3:   

3a. Map or Story Map Request Description 

3b. Map or Story Map Requested Completion Date  

8. If you have documents you would like to attach to your request, please email them to [email]. 
   (Example documents: sample budget, grant narrative, etc.)

9. Acknowledgement 

By checking this box, I acknowledge that all requests for assistance are subject to the availability and existing obligations of Center K environmental health staff and that Center K retains the right to deny requests for any reason. 

Intake Survey 
Center L

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 5 min per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

 

Center L is providing free technical assistance to support the environmental justice needs of local and tribal governments and community organizations. To help us understand your needs, please provide us with feedback by filling in and submitting this form. A member of the Center L TCTAC team will respond as soon as possible. Center L will use your feedback for internal use only. 

Center L is a national provider for the EJ TCTAC Program but will also provide targeted technical assistance to its proximate region. The region includes the following states: [list]

1. Name  
   
   

2. Reason for requesting technical assistance [text box] 
   
   

3. Where is your need for technical assistance located? [select from dropdown list] 
   
   

4. Tell us more about where your need for technical assistance is located. (Multiple locations, states or regions) [text box] 
   
   

5. Organization/Institution Name 
   
   

6. Email 
    

7. Phone Number   
   
   

8. Organization Type (Mark only one oval) 

• Local Government  

• Tribal Organization 

• Non-Profit/Community-Based Organizations  

• Private Entity 

• Other  

9. Preferred method of communication (Mark only one oval) 

• Phone  

• Email  

• Either is fine  
  
  

10. Have you ever administered a federal grant? (Mark only one oval) 

• Yes 

• No 

• N/A  
  
  

11. How did you hear about our TCTAC? [text] 
    
    

12. Have you worked with any of the following entities before? (Check all that apply) 

[list of technical assistance providers]  

Captcha Section (Please verify that you are human) 

Intake Survey (1) 
Center M

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 30 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

 

The intake survey is the initial process of introducing interested organizations and communities into the technical assistance center. The questions seek to identify general information about the interested communities and organizations, their locations, technical assistance needs, and preferred communications.  From this information the Technical Assistance Center team can assess and match the interested communities and organizations with service providers 

Thank you for reaching the message center for this region’s Technical Assistance Center. Please completely fill in the prompts as they will help the Technical Assistance Center Team provide you with valuable information and resources.  

Name 

• “Short answer” 

Phone number 

• “Short answer” 

Email address 

• “Short answer” 

Organization name or Community name 

• “Short answer” 

Are you an environmental justice organization or community?  

• Yes 

• No  

In which area of EPA Region III is your organization or community located?  

• list of states

Best way to contact you 

• Email 

• Phone  

Are you contacting us to express your willingness to provide pro bono services through the Technical Assistance Center?  

• Yes 

• No 

Select the type of assistance you need 

• Mapping assistance 

• Environmental monitoring 

• Environmental sampling 

• Health assessments 

• Support engaging government agencies 

• Energy-related issues 

• Grant writing assistance 

• Communications assistance 

• Other 

If selected ‘Other’ above, please specify 

•  [answer]

Have you contacted other organizations for support, if so which ones? 

•  [answer]

Have you received support before regarding the assistance you are requesting? 

• Yes 

• No 

Additional Information? 

•  [answer]

I consent to being contacted based on the information provided. 

• “Click box” 

Thank you for completing this intake form. Your information will help us better understand your needs and provide assistance accordingly. 

Providing Technical Assistance 

Are you a member of the press inquiring about the Technical Assistance Center?  

• Yes 

• No 

How did you hear about the Technical Assistance Center?  

• “Short answer” 

What aspects of our program are you interested in learning more about? 

• Program Overview 

• Achievements and Impacts 

• Recent Developments 

• Partnerships and Collaborations 

• Upcoming Events 

• Other 

How do you prefer to receive information? 

• Press Releases 

• Email Updates 

• Social Media Updates 

• Webinars or Virtual Briefings 

• One-on-one Interviews 

• Other 

What type of content are you most interested in? 

• “Short answer” 

Please share any additional comments or specific topics you would like us to cover in our communications 

• “Short answer” 

If they are interested in offering free services to the Technical Assistance Center  

How did you hear about our program? 

• “Short answer” 

What motivates you to offer pro bono services to our program? 

• Belief in the program’s mission 

• Expertise alignment with program needs 

• Previous positive experiences 

• Social responsibility 

• Other 

Please specify the areas in which you can provide free services. 

• “Short answer” 

What type of free engagement are you considering? 

• “Short answer” 

How would you prefer to communicate about the pro bono engagement? 

• Email 

• Phone calls 

• Virtual meetings 

What is your availability for pro bono services? 

• “Short answer” 

Please share any additional comments, suggestions, or specific expectations you may have regarding your pro bono engagement. 

• “Short answer” 

Please allow some time for someone from the Technical Assistance Center to get in touch with you. Thank you!

Intake Survey (2) 
Center M

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 30 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

 

1. Select one or more of the options below to best describe your community or the community or entity you represent: 

• Low-income community  

• Community of color  

• Disadvantaged community 

• State government  

• Local government  

• Tribal government  

• Other government  

• None of the above 
  
  

2. How confident are you with your organization’s capacity to navigate the federal U.S. Government System (i.e., Sam.gov) to search for a grant, contract, and/or other funding opportunity?  

• 1 - Completely confident in ability  

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 

 

3. Do you require training in accessing the above government system for grants, contracts, etc.? 

• Yes

• No 

 

4. In the past three years, have you submitted a federal grant proposal as a lead organization?   

• Yes

• No 

5. What types of organizations do you partner with in your work?  
   Some examples CBO, NGO, local government, state government, health departments, academic institutions, community groups, etc. 

6. Do you participate in a network, coalition, or collaborative on EEJ-focused issues in your community?  

• Yes

• No 

• If yes, please name the network:  

 

7. How would you rate your organization’s capacity to perform outreach and engagement? 

• 1 - Completely confident in capacity  

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 

8. Do you want training in outreach and engagement? 

• Yes

• No 

9. How would you rate your organization’s ability to write grant proposals? 

• 1 - Completely confident in the ability to write grants 

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 

10. Do you require training in capacity-building and direct assistance in grant writing? 

• Yes

• No 

 

10. Do you require training In financing? 

• Yes

• No 
  
  

10. How would you rate your organization’s capacity for assessing environmental justice and/or energy justice issues? 

• 1 - Completely confident in capacity 

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 
  
  

10. Do you require training in capacity-building in assessing local environmental justice and/or energy justice issues? 

• Yes

• No 
  
  

10. How would you rate your organization’s capacity for engaging government agencies in decision-making to address local environmental justice and/or energy justice issues?  

• 1 - Completely confident in capacity 

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 

 

10. Do you require training in capacity-building and direct assistance in engaging government agencies as described above? 

• Yes

• No 

 

10. How would you rate your organization’s capacity for engaging policy-makers in decision-making to address local environmental justice and/or energy justice issues?  

• 1 - Completely confident in capacity  

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 
  
  

10. Do you require training in capacity-building and direct assistance in engaging policy-makers as described above? 

• Yes

• No 
  
  

10. How would you rate your organization’s capacity for engaging businesses that can help address local environmental justice and/or energy justice issues?  

• 1 - Completely confident in capacity   

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 
  
  

10. Do you require training in capacity-building and direct assistance in engaging businesses as described above? 

• Yes

• No 
  
  

10. How confident are you with your organization’s ability to develop workforce development initiatives to address local environmental justice and/or energy justice issues?  

• 1 - Completely confident in ability  

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 
  
  

10. Do you require training in workforce development? 

• Yes

• No 

10. How confident are you with your organization’s ability to develop a business that can help address local environmental justice and/or energy justice issues? 

• 1 - Completely confident in ability  

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 
  
  

10. Do you require training in developing a business to address the above issues? 

• Yes

• No 
  
  

10. How confident are you with your organization’s ability to participate in entrepreneurship activities that can help address local environmental justice and/or energy justice issues?  

• 1 - Completely confident in ability  

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin

 

10. Do you require training in entrepreneurship? 

• Yes

• No 

10. How would you rate your organization’s capacity to access tax incentives (credits) to address your local environmental justice and/or energy justice issues? 

• 1 - Completely confident in capacity  

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin

 

10. Do you require training in accessing tax incentives (credits)? 

• Yes

• No 

 

10. How would you rate your organization’s capacity for engaging industries in developing and implementing solutions to help address local environmental justice and/or energy justice issues?  

• 1 - Completely confident in capacity   

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 

10. Do you require training in capacity-building and direct assistance in engaging industries as described above? 

• Yes

• No 

 

10. Do you have an open-door policy to meet with an industry for community engagement? 

• Yes

• No 

 

10. How confident are you with your organization’s ability to utilize mapping tools to help identify and prioritize underserved, rural, and resource-constrained communities in the region? 

• 1 - Completely confident in ability  

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 
  
  

10. Do you require training to utilize mapping tools to identify communities of concern in the region?  

• Yes

• No  
  
  

10. How confident are you with your organization’s ability to utilize mapping tools to illustrate and track local environmental justice and/or energy justice issues? 

• 1 - Completely confident in ability  

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 
  
  

10. Do you require training to utilize mapping tools to illustrate and track local environmental justice and/or energy justice issues?  

• Yes

• No  

 

10. Do members of the community that you serve have access to digital infrastructure such as Wi-Fi, internet platforms, social media, and/or internet-enabled mobile devices? 

• Yes

• No 

 

10. Do members of the community that you serve have the digital literacy needed to access information on internet platforms, social media, and mobile devices including online training, online workshops, project websites, and/or other web-based resources? 

• Yes

• No 

 

10. How confident are you with your organization’s ability to engage non-English speaking communities?  

• 1 - Completely confident in ability  

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin 

10. Do you require assistance engaging with non-English speaking communities? 

• Yes

• No 

 

10. How confident are you with your organization’s ability to translate information on local environmental justice and/or energy justice issues to non-English speaking populations?  

 

10. Do you require assistance with translation of information to non-English speaking populations in your community(ies) of concern? 

• Yes

• No 

10. How confident are you with your organization’s ability to engage with rural communities?  

• 1 - Completely confident in ability  

• 2 - Moderately confident 

• 3 - Somewhat confident 

• 4 - I know a little, but I am not confident 

• 5 - I don’t even know where to begin

 

10. Do you require capacity-building training to effectively engage rural communities? 

• Yes

• No 

 

10. Does the community have access to technology to effectively engage rural communities? 

• Yes

• No 

 

10. What sort(s) of technical assistance would your organization need to address the most important Environmental Justice and Energy Justice issues in your community?  
    Options might include: air monitors, policy and regulatory support, GIS support, advocacy training, or statistical analysis/interpretation. 

 

10. What type of legal assistance would your organization need to address the most important environmental Justice and/or energy justice issues in your community? 

 

10. Where do you go for information, support, or training related to environmental justice and/or energy justice topics?   

 

Community Information 

10. Please provide the following socio-demographic information for the community/communities you are seeking technical assistance. 

• Name of the community 

• Your first name, last name, and title 

• Your organization/business name or community affiliation (write N/A 

• if not applicable) [Response is Required] 

• Website of your organization/business (if applicable) 
  
  

10. What languages are needed for written materials?  
    
    

11. What languages are needed (including ASL) for translation services during presentations? 
    
    

12. Which of the following best describes your business/organization?  (Select all that apply) 

• Community-based or grassroots organization 

• Nonprofit organization 

• Philanthropic 

• Tribal Government or Intertribal Consortia 

• Native American Organization (includes nonprofits, cooperatives, corporations, partnerships) 

• Local Governments (as defined by 2 CFR 200.1 – includes cities, towns, municipalities, counties, public housing authorities, and councils of government) 

• Institutions of higher education (e.g., private and public universities and colleges, 

including community colleges) 

• Private business  

• Special district  

• Don't know/Not sure  

• Other (please specify) 
  
  

10. Preferred form of contact 

• Email   

• Phone call 

• SMS/text messaging 
  
  

If response to 51 = Email:  

• Please provide your Email address for future communications 
  
  

If response to 51 = phone call or SMS: 

• Please provide your phone number for future communications

Intake Survey 
Center N

 

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and record keeping burden for this collection of information is estimated to be between 5-20 minutes per response based on the level of detail the respondent provides. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

Thank you for your interest in Center N! 

The Center aims to help communities in the region, as well as the 35 Tribes within the region, successfully navigate funding opportunities for climate and environmental projects from proposal concept to grant implementation. We prioritize underserved communities, rural and remote areas, and those with the highest degree of burden and capacity constraints. 

The objective of this intake form is to understand what assistance rural, Tribal, and environmental justice communities in the region need. In collaboration with our partners, we offer an array of services to help communities and organizations receive federal funding. 

To help us better understand your needs, please fill out and submit this form to the best of your ability. A member of our staff will reach out with next steps. 

The center will use your information for internal purposes only. 

 

Personal 

1. First Name (short text field) - required 

2. Last Name (short text field) - required 

3. Email - required 

4. Phone - optional 

5. What is your preferred method of communication? - optional 

• Email 

• Phone 

• No preference 

6. Do you require any translation or interpretation services? (Yes/No) - optional 

7. (If yes) Please identify the language or interpretation service necessary.  

• Fill in

 

Organization/Tribe/Community  

7. Organization/ Tribe/community name - required 

• Fill in 

7. Location - Enter the municipality, city, state, or region for your community/Tribe, or where your organization operates - required 

• Fill in 

7. Organization/ Tribe/community website - optional  

• Fill in 
  
  

11. Organization Type (select all that apply)? - optional 

• Nonprofit 501c3 organization 

• Community-based organization that is fiscally sponsored by another 501c3 

• Philanthropic organization 

• Tribal Government or Intertribal Consortia 

• Native American Organization (includes nonprofits, cooperatives, corporations, partnerships) 

• Local Governments (as defined by 2 CFR 200.1 – includes cities, towns, municipalities, and counties, public housing authorities and councils of government) 

• Special district  

• Private business 

• Don't know/Not sure 

• Other - Fill in 
  
  

12. What is your organization/Tribe/community looking for at this moment? 

• General questions about the TCTAC 

• Help with grant planning and/ or grant management  

• All of the above. I have general questions and need help with grants. 

• Unsure 

 

Grant Information 
NOTE: These questions are shown to respondents if they selected the “Help with grant planning or management” response option in the previous question. 
 

13. Has your organization/Tribe/community received any sort of grant before (from a foundation, the state, or the federal government)? - optional 

• Yes/ No/ Unknown 
  
  

14. Has your organization/Tribe/community received a federal grant before? - optional 

• Yes/ No/ Unknown
   

15. At this time, is there a specific grant that your organization/Tribe/ community is looking for support with? - optional.  

16. (If grant selected) Have you reviewed the eligibility criteria and project requirements of your target grant(s)? - optional 

• Yes, we have reviewed the grant criteria and feel confident that it is a good fit for our organization and project. 

• Yes, we have reviewed the grant criteria, but need more guidance to determine if it is a good fit. 

• No, we have not yet reviewed any specific grant criteria and need more guidance. 

17. (If grant selected) Do you have a project in mind for any of the grant(s) you selected? - optional 

• Yes/No 

• (If yes) Please provide a brief description of the project you have in mind for each grant you selected above. - optional 

• Fill in 
  
  

18. Are you partnering with any other organizations on this project? - optional  

• Yes/Maybe/No 

• (If yes) What organizations are you partnering with? - optional 

• Fill in 
  
  

19. Is there a grant application deadline your organization/Tribe/ community needs to meet? – optional 

• Yes/No  

• (If yes) What deadline date do you need to meet? - optional 

 

Technical Assistance Support 

20. At this time, what type(s) of technical assistance would be most helpful (check all that apply)?  

• Federal grant registration (e.g., SAM.gov) 

• Grant identification 

• Grant eligibility clarification 

• Grant application assistance (e.g., grant checklist, grant proposal review) 

• Assistance in using EPA or other mapping resources to analyze proposal eligibility or add to proposal strength 

• Project design and development (e.g., help define objectives or outcomes, help obtain supporting documentation)

Intake Survey 
Center O

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 10 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

  

1. CONTACT 
   
   

Identify the organization and the main point of contact. 

1. Name: 

2. Email: 

3. Phone number: 

4. Organization: 

5. Location: 

6. Website: 

7. Preferred method of communication (phone/email): 

8. How did you hear about Center O? 
   
   

2. SCOPE: Clarify Goals & Priorities  
   
   

Better understand the organization’s goals and priorities and opportunities for technical assistance. 
If there is a technical assistance request, identify whether it aligns with the center’s environmental/energy justice TCTAC regional focus and the center’s expertise, resources, and capacity. Identify other TA providers that might serve the organization. 

1. What general category best describes who you represent? (e.g., Tribal, University/academic, Community organization, government) 
   
   

2. What is your organization’s mission and vision? 
   
   

3. What communities or populations does your organization serve? 
   
   

4. What are your organization’s long-term goals? 
   
   

5. What are your organization’s shorter-term priorities that would help move your organization towards its goals? 
   
   

6. What problems does your organization want to solve and what are you hoping to improve? (e.g., In order of importance, list your top 3 environmental and/or energy justice concerns or challenges?  List the top 3-5 barriers you have experienced while trying to address these environmental and/or energy justice concerns or challenges? 
   
   

7. Are the problems and issues related to environmental and energy justice? 
   
   

8. Are you seeking capacity building and/or funding opportunities to accelerate progress towards your priorities and goals? 
   
   

9. If so, what type of assistance are you seeking? 

1. Pre-award request (identify funding; build a proposal, etc.) 

2. Post-award management  
   
   

10. Where do you feel like your organization could use the most support or assistance? What are your priorities in requesting and receiving technical assistance from Center O? For example: 

1. Assistance with identify EEJ needs and challenges 

2. Assistance with conducting EEJ analyses to address your concern.  

3. Assistance with identifying, applying to, and managing EEJ Grants.  

4. Assistance with facilitating community engagement to address your EEJ challenges or concerns. 

5. Assistance with building partnerships across organizations to address EEJ issues. 

6. Assistance with building capacity to strengthen and focus your work on EEJ issues. 

7. Assistance with fostering community leadership to identify and address EEJ solutions. 

8. Assistance with convening meetings and facilitating partnership-building to more effectively develop collaborative proposals. 

9. Assistance with using EPA and other agencies’ mapping tools like EJSCREEN, CEJST, or the state tools. 

10. Assistance with designing environmental monitoring projects for proposals, for example developing an effective monitoring program using low-cost air quality sensors. 

11. Assistance with integrating traditional ecological knowledge or indigenous systems of knowledge to meet data gaps among tribal nations and communities 

12. Assistance with identifying research questions, goals and aims, and research methods in grant proposals. 

13. Assistance with questions related to Quality Assurance Project Plans (QAPPs) 

14. Assistance with research ethics 

15. Assistance with understanding the process of Institutional Review Board (IRB) human subjects’ protocols, including tribal IRBs. 

16. Assistance with other concerns or challenges. 
    
    

10. Are you seeking to serve in the center (e.g., as an Advisory Board member, student TA provider, Indigenous Scholar)? If so, in what way? 
    
    

3. TA REQUEST: General Environmental/Energy Justice Technical Assistance 
   
   

Some technical assistance requests may not involve applications for funding (e.g., they could be requesting assistance with existing grant/program, requesting assistance with a needs assessment, accessing data/information, conducting a needs assessment, etc. These are generally assistance activities not tied to a particular grant, or work that needs to be done to build capacity or collect preliminary information to develop future environmental/energy justice programs or grant applications. 

1. Are there specific areas of technical assistance that your organization seeks from the center?  For example: 

1. Conducting environmental justice analyses and needs assessments   

2. Facilitating meaningful engagement with other EEJ stakeholders and decision-makers  

3. Building capacity to strengthen and focus their work on EEJ issues  

4. Fostering community leadership in developing EEJ solutions  

5. Engaging students affiliated with Center O in technical assistance opportunities 
   
   

2. What is your timeline? 
   
   

3. How would the TA either help you build capacity or lead to future funding towards your priorities and goals? 
   
   

4. Who is available in your org. for us to work with?
   
   

 

4. TA REQUEST: Applying for a Grant 
   
   

Some technical assistance requests involve applications for funding. In these cases, we need to identify at which stage of the application process they require assistance. Based on this, we may be able to assist with the appropriate stage (e.g., Finding Opportunities, Developing Proposal). 

1. Does your organization have a 501c3 status or a fiscal sponsor? 
   
   

2. Does your organization have staff to write a grant? Or who in your organization currently writes grants (ED or op director or staff, etc.)? 
   
   

3. Who manages the grants you receive? Do you have either in-house grant management or a fiscal agent to assist you in managing a grant/contract?  
   
   

4. What is your organization’s experience with grants (federal, state, private, etc.)? What sizes of grants does your organization have experience applying for and managing? 
   
   

5. What type of grant does your organization want to apply for (federal, state, private, etc.)? Do you have a specific grant in mind already? 
   
   

6. What size of grant does your organization want to apply for? (i.e. dollar amount, number of years, etc.) 
   
   

7. When do you aspire to apply for funding? What is your timeline for preparing a proposal? 
   
   

8. What is your organization’s history with federal grants? Have you registered to be able to apply for federal grant opportunities (i.e., gotten a UEI number)? 
   
   

9. Has your organization applied before for a federal grant? If yes, were you successful in obtaining the grant and completing the work? 
   
   

10. Is your organization familiar with Grants.gov and other tools for searching for opportunities? 
    
    

11. Is your organization familiar with environmental and energy justice grant opportunities related to the TCTAC program, such as EPA Grantmakers program? 
    
    

12. Who is available in your org for us to work with? 
    
    

5. TA REQUEST: Find Opportunities 

 

Find grant opportunities that are aligned with the TA recipient’s goals and priorities: Assist in searching for and screening each potentially funding opportunity. 

1. What are the key factors that need to be considered for each potentially funding opportunity (e.g., funding topic, eligibility, deadline, amount and duration of funding)? 
   
   

2. What are alternative funding opportunities, e.g., from regional/state agencies, philanthropic organizations that can also be considered? 
   
   

6. TA REQUEST: Develop Proposal 
   
   

Although TCTACs are not allowed use EPA funds to write proposals for TA recipients, we may be able to assist the organization develop a proposal timeline, brainstorm ideas, provide feedback on drafts to identify strengths/weaknesses that can lead to a more competitive proposal. 

1. In 1 page, what is your “funding pitch” for the funding opportunity you’ve identified? 
   
   

2. Who will lead the proposal (i.e., the Principal Investigator/Director and lead organization)?
   Who else will be involved in the project (implementation, management, etc)? 
   
   

3. Are there other partners outside of the organization involved? 
   
   

4. What is the timeline and milestones for writing the proposal? 
   
   

5. Who will be responsible for writing the proposal? 
   
   

7. TA REQUEST: Post Award Assistance 
   
   

Organizations that have developed successful environmental/energy justice proposals, may need assistance in setting up their grant/contract or with compliance issues over the lifetime of their grant/contract. 

1. What are areas the TA recipient wants support from TCTAC specific to post-award management? 
   
   

2. Does the TA recipient have difficulty establishing the grant contract? 
   
   

3. Are there challenges with regulatory approvals (human subjects, quality control processes, etc.)? 
   
   

4. Are there other technical areas related to environmental and energy justice that benefit from TCTAC advice? 
   
   

5. Does the TA recipient want help with meeting reporting requirements? 
   
   

6. Other post-award issues that TCTACs are allowed to provide TA?  
   
   
   

7. TA REQUEST: Completed Request 
   
   

The TA recipient no longer requires assistance from the TCTAC.  The TA recipient is encouraged to reach out to TCTAC later if needed.  Use the TCTAC’s Feedback Process to identify the lessons learned from the TA opportunity that might help with future TCTAC TA, including if the assistance helped the recipient meet their priorities and goals, whether serving the TA request met the Center’s goals.

 

Intake Survey 
Center P

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 15 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 

1. Name 

2. Email 

3. Phone Number 

4. City 

5. County 

6. State 

7. Zip Code  
   
   

8. Website 
   
   

9. Which method of communication do you prefer? 

1. Email 

2. Phone call 

3. Virtual call (e.g., Zoom, Teams, Google Meet, etc.) 

4. Text 

5. Any 

6. Other: _________________________ 
    

10. Do you represent/are you inquiring on behalf of a: 

1. Municipality 

2. County 

3. Neighborhood 

4. Nonprofit organization 

5. Community group 

6. Tribal nation 

7. Individual 

8. Business/Industry 

9. Other: _________________________ 
    

11. Name of community, organization, or group.  
     

12. What is your role within the community or organization that you are representing?  
     

13. Is the community in which you serve designated as a disadvantaged community? 

1. Yes 

2. No 

3. I don’t know 
    

14. What environmental and/or energy concerns do you have for your community? (select all that apply) 

1. Indoor air quality 

2. Air pollution 

3. Energy efficiency 

4. Renewable energy 

5. Climate change 

6. Transportation 

7. Drinking water quality 

8. Sewer discharges 

9. Vacant lots/Brownfields 

10. Food access 

11. Soil pollution 

12. Erosion  

13. Trash/litter 

14. Stormwater (flooding, nonpoint source pollution, standing water, etc.) 

15. Other 

16. I’m not sure 
     

15. What kind of organizational needs or questions do you have? (select all that apply) 

1. How to bring like-minded people in my community together 

2. How to gather input from the community on local EJ and/or energy justice concerns 

3. How to get community buy-in for initiatives 

4. How to engage local, state, or federal agencies 

5. How to advocate for environmental justice in our community 

6. How to develop a nonprofit board 

7. How to partner with other organizations with shared goals 

8. Other 

9. I’m not sure 

10. None 
     

16. What funding/financial questions/concerns do you have? (select all that apply) 

1. Identifying grants or other funding opportunities 

2. Grant application processes 

3. How to get a UEI? (What is a UEI?) 

4. Grant budgets 

5. Grants management 

6. How to develop a project for funding 

7. Gathering a team  

8. Other 

9. I’m not sure 

10. None 
     

17. What projects or programs are currently or have previously worked on this concern? 
     

18. Do you currently have funding to address this concern? 

1. Yes 

2. No 

3. I don’t know 
    

19. If yes, what funding? (conditional on previous question’s answer) 
     

20. Do you know how much funding you need? 

1. Yes 

2. No 
    

21. How much funding does your program/project need?
    (conditional on previous question’s answer) 
     

22. Is there anything else you would like to share? 
     

23. How did you hear about Center P? 

1. Center P website 

2. Another website 

3. Online search 

4. Social media 

5. Flyer 

6. Email 

7. Colleague/friend 

8. Event or presentation 

9. Other (with a text box)

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