Assessment of EPA Partnership Programs; 

EPA ICR No. 2225.01, OMB Control No. New

EPA Form # 6500-02

Sample Draft Questions  

10-12-06

1. Please indicate the total number of employees (members) at your
facility/organization: __________

OR circle the range of number of employees that fits closest:

‮ 1-50 ‮ 51-100 ‮ 101-500 ‮ 501-1000 ‮ 1,001-5,000 ‮ 5,000 +

2. Which of the following best describes your organization? 

	_____ Business or Industry (Please include SIC or NAICS code, if
available)

	_____ Government

	_____ Non-profit/Non-Governmental Organization

	_____ Other

3. What is your position in your organization? Check the one that best
represents your primary focus area.

_____ Environmental, health, and safety

_____ Information technology

_____ Management

_____ Contractor

_____ Production

_____ Sales/Marketing

_____ Finance

        _____ Other (please specify):
_________________________________________

4. How did you first learn about (name of partnership program)?

	_____Industry partner

	_____Web site

	_____ Brochure

	_____Conference/Meeting

	_____Other

	_____N/A

5. How important to you were the following reasons for joining (name of
partnership program)?   (1=not important to 7=very important.)

Examples:

_____ a. General information about <insert name of environmental problem
addressed by program>.

_____ b. To learn about pollution prevention opportunities.

_____ c. To receive EPA recognition for our efforts.

_____ d. To network with other organizations.

_____ e. To improve public or industry perception of our organization.

_____ f. To identify cost savings opportunities.

_____ g. To obtain technical assistance from EPA.

_____ h. To improve environmental performance

_____ i. Other (Please specify.) ___________________

6. Overall, how valuable do you find your participation in (name of
partnership program) on a scale of 1 to 7 with 7 being the most
valuable. Do you find participation in the (name of the partnership
program) to be worth the time and cost expended?

Value: _______ Because
_________________________________________________________________

7. How would you rate your understanding of the following issues before
your participation in (name of partnership program)? (1=no
understanding; 7=highest level of understanding) Select DK if you
don’t know or N/A for not applicable. 

Examples:

a. Issue 1		______

b. Issue 2		______	

8. How would you rate your understanding of the following issues after
your participation in (name of partnership program)? (1=no
understanding; 7=highest level of understanding). Select DK if you
don’t know or N/A for not applicable.

Examples:

a. Issue 1		_______

b. Issue 2		_______

9. How helpful are the following elements of the (name of partnership
program)?  Please rate from 1 to 7 with 7 being the most helpful.
(Select DK if you don’t know or N/A for not applicable.)

Examples:

Web site						

______Electronic reporting system		

______Written program materials		

______Program implementation guide	

______Introductory program brochure	

______Technical assistance

______Networking opportunities	

______EPA recognition

______Staff knowledge		

______Staff responsiveness			

______Other (please specify):
_______________________________________________________________________

How could these elements be improved?
_____________________________________________________

10. Please rate your preference for receiving information related to
(name of partnership program) (1= not preferred method, 7= preferred
method) (Select DK if you don’t know or N/A for not applicable.)

Examples:

_____ Manuals (comprehensive)

_____ E-mail

_____ Phone

_____ Fact Sheets (short, single topic)

_____ Newsletter or journal articles

_____ CDs

_____ Web sites

_____ Workshops

_____ Videos

_____ Other (please specify):_________________________________________

11.  What internal activities has your organization conducted as a
result of your participation in (name of partnership program) [Insert
time period]?    (Check all that apply.) (You will have the opportunity
to quantify cost savings and environmental results associated with these
activities in Questions 14-21 below).

Examples:

______ a. Food grown under integrated pest management (IPM), organic, or
other environmentally-friendly food labeling programs

______ b. Adoption of IPM and other environmental stewardship practices

______ c. Promoted integrative vegetative management (IVM) techniques

______ d. Other (please specify):
_______________________________________

______ e. Don’t Know

______ f. Not Applicable

12.  What management changes, if any, at your facility/organization did
you take as a result of your participation in (name of partnership
program) [Insert time period]?     (Check all that apply.)

Examples:

_____ a. Conducted a self audit

_____ b. Established an environmental management system

_____ c. Instituted training or other communication to improve awareness
and/or practices

_____ d. Developed a “green team”

_____ e. Took no management action

_____ f. Other (please specify):
______________________________________________________

______g. Don’t Know

_____ h. Not Applicable

13.  What external activities did you conduct as a result of your
participation in (name of partnership program) [Insert time period]?
(Check all that apply.)

Examples:

_____ a. Referred the program to customers, industry colleagues, or
suppliers 

_____ b. Publicized participation in the program to the community and
other stakeholders

_____ c. Encouraged parent/sister organizations to participate in the
program

_____ d. Issued new requirements to suppliers (e.g., participation in
the program, change of specifications)

_____ e. No external activities will be conducted

_____ f. Other (please specify):
___________________________________________________________

______g. Don’t Know

_____ h. Not Applicable

14. What have been other benefits, if any, for your
facility/organization participating in (name of partnership program)?
(Check all that apply.)

Examples:

_____ a. Improved quality of products

_____ b. Improved worker health and safety

_____ c. Increased employee satisfaction/morale

_____ d. Public recognition

_____ e. Access to resources and technical assistance

_____ f. Improved efficiency (e.g., less waste, better processes, etc.)

_____ g. Other: ______________

_____ h. No benefit

15. Please describe the environmental benefits of any GREEN DESIGN
changes undertaken [Insert time period] as part of your participation in
(name of partnership program): 

Activity	Amount Before Design Change	Amount After Design Change	Total
Change	Number of Units Planned for Production

(e.g., Redesigned product to eliminate lead and mercury)	_____ Mercury
per unit

_____ Other 

_____ Don’t Know	_____ Mercury per unit

_____ Other

_____ Don’t Know	_____ Mercury per unit

_____ Other

_____ Don’t Know	_____ Units

_____ Other





16. Please identify any change in GREEN PURCHASES (or sales) as a result
of participation in (name of partnership program) [Insert time period].
If available, please provide the amount of change:

Activity	Amount Before Implementing Activity	Amount After Implementing
Activity	Total Change

(e.g., Began using green power for 25% of operations)	_____ Megawatts OR
____BTUs of green energy

______Dollars spent on environmentally-preferable products

______Certified water efficient products

______Biopesticides

______Organic or slow-release fertilizers

______Other:__________________

_____ Don’t Know

	_____ Megawatts OR ____BTUs of green energy

______Dollars spent on environmentally-preferable products

______Certified water efficient products

______Biopesticides

______Organic or slow-release fertilizers

______Other:_________________

_____ Don’t Know	_____ Megawatts OR ____BTUs of green energy

______Dollars spent on environmentally-preferable products

______Certified water efficient products

______Biopesticides

______Organic or slow-release fertilizers

______Other:___________________

_____ Don’t Know



If other factors aside from the actions taken impacted these results
(e.g., production decreased by 50 percent, change in total sales
occurred, or change in number of employees occurred), please indicate
that here.
________________________________________________________________________
_____________________________________

17. Please identify any change in RAW MATERIALS, process input supplies,
and feedstocks that resulted, from the actions taken [Insert time
period] as a result of participation in (the partnership program). If
available, please provide the amount of the changes).

Activity	Amount of Feedstock Used Before Implementing Activity	Amount of
Feedstock Used After Implementing Activity	Total Change

(e.g., Lightweighted primary packaging)

Capital Costs ________

Cost Savings ________

(if known)	_____ pounds of hazardous materials or toxic chemicals
(chemical name______)

_____ pounds of non-hazardous materials (e.g., packaging) (type of
material: e.g., paper, plastic, glass_______________)

_____ Other:___________________

_____ Don’t Know	_____ pounds of hazardous materials or toxic
chemicals (chemical name______)

_____ pounds of non-hazardous materials (type of material: e.g., paper,
plastic_______________)

_____ Other:___________________

_____ Don’t Know

	_____pounds hazardous material or toxic chemicals

______pounds of non-hazardous materials

(type of material: e.g., paper, plastic_______________)

_____ Other:___________________

_____ Don’t Know



If other factors aside from the actions taken impacted these results
(e.g., production decreased by 50 percent, change in total sales
occurred, or change in number of employees occurred), please indicate
that here.  ___________________________________________________________

Please briefly describe how you measured these results (e.g., compared
utility bills and after implementation) ____________________ 

If you provided cost savings, how were the savings calculated (e.g.,
avoided purchasing costs, avoided labor costs) _______________________

18. Please identify any change in NATURAL RESOURCE use that resulted
from the actions taken [Insert time period] as a result of participation
in (the partnership program) If available, please provide the amount of
the reduction(s):

Activity	Amount Natural Resource Used Before Implementing Activity
Amount of Natural Resource Used After Implementing Activity	Total Change

(e.g., Installed high-efficiency bathroom fixtures)

Capital Costs ________

Cost Savings ________

(if known)	_____ gallons of water 

_____ megawatts OR ____ BTUs of energy 

_____ gallons of fuel

_____ organic material

_____ Other:___________________

_____ Don’t Know

	_____gallons of water 

_____megawatts OR ____ BTUs of energy 

_____ gallons of fuel

_____ organic material

_____ Other:___________________

_____ Don’t Know	_____gallons of water conserved

_____megawatts OR ____ BTUs of energy

_____gallons of fuel 

_____organic material

_____Other:___________________

_____ Don’t Know

	_____ gallons of water 

_____ megawatts OR ____ BTUs of energy 

_____ gallons of fuel

_____ organic material

_____ Other:___________________

_____ Don’t Know

	_____gallons of water 

_____megawatts OR ____ BTUs of energy 

_____ gallons of fuel

_____organic material

_____ Other:___________________

_____ Don’t Know	_____gallons of water conserved

_____megawatts OR ____ BTUs of energy

_____gallons of fuel 

_____organic material

_____ Other:___________________

_____ Don’t Know



If other factors aside from the actions taken impacted these results
(e.g., production decreased by 50 percent, change in total sales
occurred, or change in number of employees occurred), please indicate
that here.  ___________________________________________________________

Please briefly describe how you measured these results (e.g., compared
utility bills and after implementation) ____________________ 

If you provided cost savings, how were the savings calculated (e.g.,
avoided purchasing costs, avoided labor costs) _______________________

19. Please identify any change in a POLLUTANT(S) EMISSIONS OR WASTE
that resulted from the actions taken [Insert time period] as a result of
participation in (the partnership program). If available, please provide
the amount of the reduction(s):

Activity	Amount of Pollution or Waste Generated Before Implementing
Activity	Amount of Pollution or Waste Generated After Implementing
Activity	Total Change

(e.g., Change to low-VOC coating operations)

Capital Costs ________

Cost Savings _______

(if known)	_____ pounds of solid waste

_____ pounds of hazardous waste 

_____ pounds of air emissions 

_____ pounds of NOx

_____ pounds of water pollutants/nitrogen

_____ pounds/gallons of chemicals

_____ Other:___________________

_____ Don’t Know

	_____pounds of solid waste

_____ pounds of hazardous waste 

_____ pounds of air emissions

_____ pounds of NOx

_____ pounds of water pollutants/nitrogen

_____ pounds/gallons of chemicals

_____ Other:___________________

_____ Don’t Know	_____pounds of solid waste

_____pounds of hazardous waste

_____pounds of air emissions

_____pounds of NOx

_____pounds of water pollutants/nitrogen

_____ pounds/gallons of chemicals

_____ Other:___________________

_____ Don’t Know

	_____ pounds of solid waste

_____ pounds of hazardous waste 

_____ pounds of air emissions 

_____ pounds of NOx

_____ pounds of water pollutants/nitrogen

_____ pounds/gallons of chemicals

_____ Other:___________________

_____ Don’t Know

	_____pounds of solid waste

_____ pounds of hazardous waste 

_____ pounds of air emissions

_____ pounds of NOx

_____ pounds of water pollutants/nitrogen

_____ pounds/gallons of chemicals

_____ Other:___________________

_____ Don’t Know	_____pounds of solid waste

_____pounds of hazardous waste

_____pounds of air emissions

_____ pounds of NOx

_____pounds of water pollutants/nitrogen

_____ pounds/gallons of chemicals

_____ Other:___________________

_____ Don’t Know



If other factors aside from the actions taken impacted these results
(e.g., production decreased by 50 percent, change in total sales
occurred, or change in number of employees occurred), please indicate
that here. 
________________________________________________________________________
________________________________________________

Please briefly describe how you measured these results (e.g., Compared
disposal volume provided by hauler before and after implementation

If you provided cost savings, how were the savings calculated (e.g.,
avoided disposal costs) 

________________________________________________________________________
________________________________________________20. Please identify
amount of materials REUSED that resulted from actions taken [Insert time
period] as a result of participation in (the partnership program). If
available, please provide the amount reused: 

Activity	Amount of Material Reused Before Implementing Activity	Amount
of Material Reused After Implementing Activity	Total Amount Reused



(e.g., Donated computers for reuse by schools, reused water for
landscaping)

Capital Costs_________

Cost Savings ________

(if known)	_____ computer monitors

_____ computer CPUs

_____ laptop computers

_____ printers

_____ cell phones

_____ pounds of paper

_____ pounds of glass

_____ pounds of plastic

_____ pounds of organic material

 _____gallons of fuel

_____ gallons of water

_____ Other

______Don’t Know

	_____ computer monitors

_____ computer CPUs

_____ laptop computers

_____ printers

_____ cell phones

_____ pounds of paper

_____ pounds of glass

_____ pounds of plastic

_____ pounds of organic material

 _____gallons of fuel

_____ gallons of water

_____ Other

______Don’t Know

	 _____computer monitors

_____ computer CPUs

_____ laptop computers

_____ printers

_____ cell phones

_____ pounds of paper

_____ pounds of glass

_____ pounds of plastic

_____ pounds of organic material

 _____gallons of fuel

_____ gallons of water

_____ Other

______Don’t Know



If other factors aside from the actions taken impacted these results
(e.g., production decreased by 50 percent, change in total sales
occurred, or change in number of employees occurred), please indicate
that here. 
________________________________________________________________________
________________________________________________

Please briefly describe how you measured these results (e.g., Compared
disposal volume provided by hauler before and after implementation

If you provided cost savings, how were the savings calculated (e.g.,
avoided disposal costs) 

________________________________________________________________________
________________________________________________

21. Please identify amount of materials RECYCLED that resulted from
actions taken [Insert time period] as a result of participation in (the
partnership program). If available, please provide the amount recycled: 

Activity	Amount of Material Recycled Before Implementing Activity	Amount
of Material Recycled After Implementing Activity	Total Amount Recycled



(e.g., Computers sent to recycling facilities, cans donated to school
groups for recycling)

Capital Costs _______

Cost Savings _______

(if known)	_____ computer monitors

_____ computer CPUs

_____ laptop computers

_____ printers

_____ cell phones

_____ pounds of paper

_____ pounds of glass

_____ pounds of aluminum

_____ pounds of plastic

_____ pounds of organic material

 _____gallons of fuel

_____ gallons of water

_____ Other

_____ Don’t Know

	_____ computer monitors

_____ computer CPUs

_____ laptop computers

_____ printers

_____ cell phones

_____ pounds of paper

_____ pounds of glass

_____ pounds of aluminum

_____ pounds of plastic

_____ pounds of organic material

_____ gallons of fuel

_____ gallons of water

_____ Other

_____Don’t Know	 _____computer monitors

_____ computer CPUs

_____ laptop computers

_____ printers

_____ cell phones

_____ pounds of paper

_____ pounds of glass

_____ pounds of aluminum

_____ pounds of plastic

_____ pounds of organic material

_____ gallons of fuel

_____ gallons of water

_____ Other

______Don’t Know



If other factors aside from the actions taken impacted these results
(e.g., production decreased by 50 percent, change in total sales
occurred, or change in number of employees occurred), please indicate
that here. 
________________________________________________________________________
________________________________________________

Please briefly describe how you measured these results (e.g., Compared
disposal volume provided by hauler before and after implementation

If you provided cost savings, how were the savings calculated (e.g.,
avoided disposal costs) 

________________________________________________________________________
________________________________________________

22. Please describe any other additional environmental benefits [Insert
time period] (not already captured above) achieved by your organization
as a result of participation in the partnership program (e.g., wildlife
benefits, greenhouse gas reductions, reduced school absences attributed
to pesticide
exposure):______________________________________________________________
______________________________

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Partnership Programs using the generic ICR may select from these
questions to design a tailored questionnaire for their specific needs.
Regarding the questions listed below, bolded questions will not change.
However, answer choices (a, b, c, d, etc.) and examples can be tailored
to the requirements of a specific Partnership Program.

