FOLLOW-UP QUESTIONNAIRE: RETROSPECTIVE

Name of Activity: ___________________________ Date of Activity:
_________________

Please indicate how strongly you agree or disagree with each statement
by circling a number between 1 and 5. 1 means you disagree completely. 5
means you agree completely. If the question is not applicable, select
NA.

	Completely Disagree	Generally Disagree	Neither Agree nor Disagree
Generally Agree	Completely Agree	Not Applicable

Because of [the activity] I took actions that I would not have taken
otherwise.	1	2	3	4	5	NA



The public reporting and recordkeeping burden for this collection of
information is estimated to average 5 minutes per response. Send
comments on the Agency's need for this information, the accuracy of the
provided burden estimate, and any suggested methods for minimizing
respondent burden, including through the use of automated collection
techniques to the Director, Collection Strategies Division, U.S.
Environmental Protection Agency (2822T), 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.

OMB Control No. 2030-XXXX

Approval Expires xx/xx/xx

EPA Form 6600-02   

