Co-designing with (not for) Communities Focus Group

Registration for USFWS Discussion with our Closest Neighbors

OMB Control No. 1090-0012 (expires 2/28/2027)

Estimated time to complete: 5 minutes

All responses are voluntary

Send comments about this form to: [email protected]

Thank you for your interest! You can help us learn about your community to understand and meet your community, and to better understand and meet community goals. Specifically, the United States Fish and Wildlife Service (USFWS) is looking for local residents who are interested in discussing the future of our programs and how they could benefit our surrounding communities. This form will ask you to share some basic information with us regarding if and how you would like to participate in this discussion. All questions on this form are voluntary – you may answer as many or as few as you wish, including none at all, without any repercussions.

It should take around 5 minutes to complete the questions. Your contact information will only be shared with the USFWS and our project partner, With (Not For) Communities. All other information will only be used to help us make programs that meet the needs of the community.

1. Please select your choice below. Clicking on the "agree" button below indicates the * following:

• you have read the above information

• you voluntarily agree to participate

• you are at least 18 years of age

**If you do not wish to participate, please decline participation by clicking on the "disagree" button below.

Mark only one oval.

I agree

I do not agree

As a reminder, all questions on this survey, including the below questions, are completely voluntary. You may answer as many or as few questions as you wish, including none at all, without any repercussions. Please note - this information will be used to ensure that our focus groups represent a diversity of experiences. It will not be used for other purposes.

2. First and Last Name *

3. Phone Number *

4. Email Address *

5. Your age (must be 18 or older to participate) *

Mark only one oval.

18-24

25-34

35-44

45-54

55-64

65 and older

6. What gender do you most identify with? (Please select all that apply) *

Check all that apply.

Male

Female

Non-binary

Self-Identify Prefer not to say

7. How would you describe yourself (Please check all that apply): *

Check all that apply.

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

8. Your household income *

Mark only one oval.

< $31,000

$31,000 - $50,000

> $50,000

9. What community do you live in?

Mark only one oval.

Bacontown, MD

Maryland City, MD

North Laurel, MD

South Laurel, MD

Laurel, MD

Ward 4, RI

North End, RI

10. How Would you Like To Participate In The Discussion?

VIRTUAL - A computer and internet connection are required. Discussion Group participants will receive a $25 VISA gift card.

IN-PERSON DISCUSSION - Discussion Group participants will receive a $25 VISA gift card.

10. Please select DISCUSSION GROUP(S) that YOU WOULD BE AVAILABLE to participate in. You'll only be asked to participate in one discussion group and we'll connect with you soon about which date you have been chosen to attend.

Check all that apply.

Friday, September 23, 2024 at 12 - 1:30 p.m.

Wednesday, October 1, 2024 at 6:00 - 7:30 p.m.

Saturday, October 12, 2024 at 10:00 - 11:30 a.m.

Sunday, October 19,, 2024 at 3:00 - 4:30 p.m.

Tuesday, October 25, 2024 at 6:00 - 7:30 p.m.

Tuesday, November 2, 2024 at 6:00 - 7:30 p.m

12. If participating in a discussion group, will you need childcare? *

Mark only one oval.

I will NOT require childcare if I participate in a discussion group.

I WILL require childcare if I participate in a discussion group.

13. If participating in a discussion group, will you need to be reimbursed for transportation? This will include receiving a gift card for a Lyft or Uber ride. *

I will NOT require reimbursement for transportation if I participate in a discussion group.

I WILL require reimbursement for transportation if I participate in a discussion group.