Dear Partners,

	The U.S. Environmental Protection Agency (EPA) is soliciting feedback
from Partners on their experiences and suggestions under the Schools
Chemical Cleanout Campaign (SC3).  On an annual basis, we will ask
Partners to complete the enclosed survey and return it to us.  The
survey helps us learn about your accomplishments and the impacts being
made in schools.  It also helps us identify needs and concerns that you
have and how best to address them.  Finally, it helps us determine the
future direction of the Program.

The survey is organized as follows:

Part 1 asks for general information about your company (e.g., how you
became aware of the SC3 Program).

Part 2 asks for information on the services and resources that your
company has provided to schools (e.g., support on chemical inventories,
etc.).

Part 3 asks for lessons learned under the Program (e.g., your successes
and barriers to success) that can be shared with others.  Part 3 also
asks about your future involvement under the Program.

Worksheets are attached at the end of the survey to help you provide
some responses. 

Each question in the survey includes brief instructions on how to
provide a response.  Please enter your responses electronically into the
spaces provided on the survey.  If additional space is needed, please
attach additional pages.  We also would welcome any of your work
products that can be shared with others at the SC3 web pages (e.g.,
training materials that you developed).  Finally, if you completed a SC3
Survey last year, please use that version to respond to this year’s
survey.  Please update it for the past 12 months and submit it to us.  

Surveys should be submitted no later than TBD of each year by any of the
following methods:

1.	Emailed to:   HYPERLINK "mailto:merse.cynthia@epa.gov" 
merse.cynthia@epa.gov .

Faxed to: 703-308-8433 (c/o Cynthia Merse).

Special delivery (e.g., FedEx) to:

Cynthia Merse, N-6935

Two Potomac Yard

2733 S. Crystal Drive 

Arlington, VA 22202

If you have any questions about the survey, please contact Cynthia Merse
at EPA by phone (703-308-0020) or e-mail (  HYPERLINK
"mailto:merse.cynthia@epa.gov"  merse.cynthia@epa.gov ).  Thanks in
advance for your timely completion of the survey. 

Sincerely,

	TBD

Office of Solid Waste

Enclosure

DRAFT SURVEY INSTRUMENT:

SCHOOLS CHEMICAL CLEANOUT CAMPAIGN (SC3)

PART 1: GENERAL INFORMATION ON PARTNER

1.1  	How did your company become aware of the SC3 Partner Program?
(Check all that apply.) 

	  FORMCHECKBOX    SC3 web site

	  FORMCHECKBOX    Trade organization

	  FORMCHECKBOX    Newsletter or other print media

	  FORMCHECKBOX    Conference or exhibition

	  FORMCHECKBOX    Word of mouth

	  FORMCHECKBOX    Other, please specify:   FORMTEXT        

  FORMCHECKBOX    Do not know

1.2 	Why did your company choose to become involved in SC3 activities? 
Please review the possible reasons for joining SC3 in the table.  Place
an “X” in the appropriate box to indicate the relevance of each
reason based on a 1 to 5 scale (1 means “completely irrelevant” and
5 means “highly relevant.”  Please include other reasons in the
table if needed and indicate their relevance.  

Possible Reasons for Joining SC3	Relevance to Your Company  

	1

(Completely irrelevant)	2	3	4	5

(Highly relevant)

Enhance your company’s relationship with the community	  FORMCHECKBOX 
	  FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  

Carry out the organizational mission or responsibility of your company	 
FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  	 
FORMCHECKBOX  

Establish new business relationships (e.g., business development)	 
FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  	 
FORMCHECKBOX  

Enhance existing business relationships 	  FORMCHECKBOX  	  FORMCHECKBOX
 	  FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  

Obtain credit under Performance Track	  FORMCHECKBOX  	  FORMCHECKBOX  	
 FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  

Other, please specify:   FORMTEXT             	 
FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  	 
FORMCHECKBOX  



1.3 	Has your company conducted chemical inventories, cleanouts and/or
other chemical management activities at schools prior to your
involvement with SC3?

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

  FORMCHECKBOX    Do not know

1.4	How many hours and dollars has your company spent in providing
services and resources to schools since joining the Program?  Please
provide your response in Worksheet 1 at the end of this survey.

1.5	Has your company encouraged other companies or associations to join
SC3?  If you select “No,” please briefly explain why not.

	

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No 

  FORMTEXT        

1.6	Has your company encouraged schools to join SC3?  If you select
“No,” please briefly explain why not.

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No 

  FORMTEXT        

Does your company partner with EPA in any other Partnership Program(s)?
(Check all that apply.)

  FORMCHECKBOX    Performance Track

	  FORMCHECKBOX    WasteWise

	  FORMCHECKBOX    National Partnership for Environmental Priorities
(NPEP)

  FORMCHECKBOX    Other, please specify:   FORMTEXT        

  FORMCHECKBOX    Do not know

PART 2: DESCRIPTION OF SERVICES AND RESOURCES PROVIDED

2.1 	Chemical Inventory

2.1.1	Has your company performed a chemical inventory at a school since
joining the program?  If you select “Yes,” please complete the
remainder of this section.  If you select “No,” proceed to section
2.2.

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No

Please indicate the number of schools that have received support in
chemical inventories from your company and the approximate number of
students and staff in those schools.  (Information on school enrollment
may be available on-line.)

Number of Schools	Number of Students	Number of 

Staff

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      



Were these schools performing chemical inventories prior to your
involvement with them? (Additional space is provided below if you need
to explain your answer.)

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

  FORMCHECKBOX    Do not know

  FORMTEXT        

2.1.4	What chemical inventory activities has your company performed
since joining the Program? (Check all that apply.)

  FORMCHECKBOX    Identified possible locations of chemicals before
walk-through/inspection

  FORMCHECKBOX    Performed walk-through/inspection of all relevant
locations for chemicals

  FORMCHECKBOX    Addressed safety hazards during
walk-through/inspection (e.g., developed a plan to prevent and clean up
spills)

  FORMCHECKBOX    Documented chemicals found 

  FORMCHECKBOX    Established a sustainable chemical inventory program
(i.e., a permanent program)

  FORMCHECKBOX    Other, please specify:   FORMTEXT        

2.1.5	What chemicals have you assisted in inventorying since joining the
Program?  Please provide your response in Worksheet 2 at the end of this
survey.

2.1.6	Did your company encounter unknown chemicals (i.e.,
“unknowns”) during the inventory process?  If you select “Yes,”
please respond to Question 2.1.7.  If you select “No,” proceed to
section 2.2.

  FORMCHECKBOX    Yes 

	  FORMCHECKBOX    No

2.1.7	What actions did you take in addressing unknown chemicals during
the inventory?  (Check all that apply.)

  FORMCHECKBOX   Sent unknowns to a lab for testing before offsite
shipment

  FORMCHECKBOX  	Tested unknowns on site (e.g., by contractor) before
offsite shipment

  FORMCHECKBOX    Used non-testing methods to characterize unknowns
(e.g., by interviewing faculty)

  FORMCHECKBOX    Did not characterize unknowns before offsite shipment

  FORMCHECKBOX    Removed unknowns to a safe location pending offsite
shipment

  FORMCHECKBOX    Other, please specify:   FORMTEXT        

  FORMCHECKBOX    Do not know

2.2	Training and Education

2.2.1	Has your company assisted in developing and/or delivering training
or education at a school since joining the program?  If you select
“Yes,” please complete the remainder of this section.  If you select
“No,” proceed to section 2.3. 

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No

Please indicate the number of schools that have received
training/educational support from your company and the approximate
number of students and staff that have received this training/education.

Number of Schools	Number of Students	Number of 

Staff

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      



Was the school (or schools) providing comparable training or education
prior to your involvement with it?  (Additional space is provided below
if you need to explain your answer.)

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

  FORMCHECKBOX    Do not know

  FORMTEXT        

Please describe your trainings/education (e.g., recipients and frequency
of 

trainings) by completing Worksheet 3 at the end of this survey. 

2.2.5   What types of training has your company helped to provide to
schools?  Please review the table below to see if you have provided any
of the types of trainings listed.  If you have, please approximate the
cumulative duration (in hours) of that training.  For example, if you
provided five two-hour classroom trainings, you would enter “10
hours” into the shaded cell for classroom training.  Note:  If you
have not provided a type of training shown in the table, then enter
“N/A” into its shaded cell.  

Types of Training:	Length of Training (hrs):

Classroom training	            FORMTEXT        

Emergency exercises (e.g., evacuation exercises)	            FORMTEXT 
      

On-the-job training (e.g., for faculty, maintenance staff)	           
FORMTEXT        

Other, please specify:   FORMTEXT             	         
  FORMTEXT        



2.2.6	Has your company assisted in the development of a sustainable
training program for schools (i.e., a training program that will be
conducted on a permanent basis by the school)?  (If you select “No,”
please briefly explain if you plan to in the future.)

  FORMCHECKBOX    Yes 

	  FORMCHECKBOX    No

  FORMTEXT        

2.3	Chemical Management Program

2.3.1	Has your company assisted in developing a chemical management
program for a school since joining the program?  If you select
“Yes,” please complete the remainder of this section.  If you select
“No,” proceed to section 2.4. 

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No

Please indicate the number of schools that have received support in
chemical management from your company and the approximate number of
students and staff in those schools. (Information on school enrollment
may be available on-line.)

Number of Schools	Number of Students	Number of 

Staff

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      



Did these schools have a chemical management program in place prior to
your involvement with them? (Additional space is provided below if you
need to explain your answer.)

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

  FORMCHECKBOX    Do not know

  FORMTEXT        

2.3.4	What elements of a chemical management program did your company
help schools to develop, implement, and/or fund?  (Check all that
apply.)

  FORMCHECKBOX  	Purchasing of chemicals (e.g., how to purchase fewer
and/or less toxic chemicals)

  FORMCHECKBOX    Chemical inventory 

  FORMCHECKBOX    Storage of chemicals

  FORMCHECKBOX  	Chemical usage (e.g., changes in a school’s
laboratory practices to minimize the quantity of chemicals used in
experiments)

  FORMCHECKBOX    Regulatory compliance

  FORMCHECKBOX    Chemical waste collection, onsite storage and disposal

  FORMCHECKBOX    Labeling

  FORMCHECKBOX    Budgeting for chemical management

  FORMCHECKBOX    Training

  FORMCHECKBOX    Safety

  FORMCHECKBOX    Development/implementation of school policies, plans
and/or procedures on proper chemical management

  FORMCHECKBOX    Development/implementation of performance goals and
measures to gauge chemical management success

      

  FORMCHECKBOX    Do not know

2.4	Packaging, Removing and Disposing of Chemical Waste

2.4.1	Has your company assisted in packaging, removing and/or disposing
of chemical waste (i.e., chemical cleanouts) since joining the program? 
If you select “Yes,” please complete the remainder of this section. 
If you select “No,” proceed to section 2.5. 

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No

Please indicate the number of schools that have received support in
chemical cleanouts from your company since joining the Program and the
approximate number of students and staff in those schools.  (Information
on school enrollment may be available on-line.) In addition, please
indicate the total number of cleanouts that your company has supported.

Number of Schools	Number of Students	Number of 

Staff	Number of 

Cleanouts

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        



Were these schools cleaning out their chemicals prior to your
involvement with them? (Additional space is provided below if you need
to explain your answer.)  If you select “No,” please answer Question
2.4.4 below.  If you select “Yes,” proceed to Question 2.4.5.

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

  FORMCHECKBOX    Do not know

  FORMTEXT        

Why had the school(s) not removed the chemicals on its own prior to your
involvement?  (Check all that apply.)

  FORMCHECKBOX    School was not aware of the problem or need

  FORMCHECKBOX    School lacked the technical expertise/personnel

  FORMCHECKBOX    School lacked the financial resources 

  FORMCHECKBOX    There was resistance within the school

      

  FORMCHECKBOX    Do not know

2.4.5  	What activities related to packaging, removing and disposing of
chemical waste has your company performed since joining the program? 
(Check all that apply.)

  FORMCHECKBOX    Collecting the chemical waste from individual rooms in
the school

  FORMCHECKBOX    Performing testing/characterization of chemical waste

  FORMCHECKBOX    Packaging the chemical waste for offsite shipment

  FORMCHECKBOX    Storing the chemical waste prior to offsite shipment

  FORMCHECKBOX    Preparing required paperwork, if any (e.g., shipping
paper)

      

  FORMCHECKBOX    Do not know

2.4.6	Did your company hire a contractor for chemical packaging,
removal, and/or disposal?  If you select “Yes,” please complete the
next question.  If you select “No,” proceed to Question 2.4.8.

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No

2.4.7  	What activities did the contractor perform?  (Check all that
apply.)

  FORMCHECKBOX    Collected the chemical waste from individual rooms in
the school

  FORMCHECKBOX    Performed testing/characterization of chemical waste

  FORMCHECKBOX    Packaged the chemical waste for offsite shipment

  FORMCHECKBOX    Prepared required paperwork, if any (e.g., shipping
paper)

  FORMCHECKBOX    Accepted the chemical waste shipment for management
and disposal

  FORMCHECKBOX    Other, please specify:   FORMTEXT        

  FORMCHECKBOX    Do not know

What chemicals have you assisted in cleaning out since joining the
program? Please provide your response in Worksheet 4 at the end of the
survey.     

                            

What is your total expenditure for removing chemicals from schools since
joining the program?  This should include any expenditure for
testing/characterization, packaging, transportation, and offsite
management/disposal. 

  FORMCHECKBOX   Less than $1,000            

  FORMCHECKBOX   $1,001 to $3,000 

  FORMCHECKBOX   $3,001 to $5,000

  FORMCHECKBOX   $5,001 to $7,000            

  FORMCHECKBOX   $7,001 to $9,000 

  FORMCHECKBOX   $9,001 to $11,000

  FORMCHECKBOX   If more than $11,000, please estimate a range (e.g.,
$13,000 to $15,000):

     $  FORMTEXT         to $  FORMTEXT        

2.5	Outreach

2.5.1	Has your company provided outreach in connection with SC3 since
joining the program?  If you select “Yes,” please complete the
remainder of this section.  If you select “No,” proceed to Part 3. 

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No

2.5.2	What was your company’s goal(s) in performing these outreach
efforts? (Check all that apply.)

  FORMCHECKBOX    Raise public awareness of SC3

  FORMCHECKBOX    Encourage organizations to join SC3

  FORMCHECKBOX    Raise awareness of the general need for chemical
safety, management, and removals in schools

      

2.5.3 	Please describe your outreach efforts (e.g., types of recipients
and outreach methods) by completing Worksheet 5 at the end of this
survey

PART 3: SUCCESSES, BARRIERS AND FUTURE ACTIVITIES

3.1	Have your company’s objectives and expectations for joining the
SC3 Program been realized to your satisfaction?

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No 

3.2  	What factors influence your company’s decision to continue in
the Program?  (Check all that apply.)

	  FORMCHECKBOX    Your company’s ability to find and partner with new
schools in need of support

	  FORMCHECKBOX    Availability of resources in your company (e.g.,
money, personnel with relevant  

                   expertise) to sustain your ongoing efforts

	  FORMCHECKBOX    Continued involvement by EPA to address your needs
and concerns 

	  FORMCHECKBOX    Other, please specify:   FORMTEXT        

		

3.3	What are your company’s plans under the SC3 Program over the
coming years?  (Check all that apply.)

	  FORMCHECKBOX   Partnering with additional schools

	  FORMCHECKBOX   Continuing to work with existing schools

	  FORMCHECKBOX   Encouraging other companies to join in the future

              FORMCHECKBOX   Other, please specify:   FORMTEXT 
      

3.4	What is your most prohibitive barrier to removing chemicals from
schools and/or implementing a responsible chemical management program? 
(Select one.)

  FORMCHECKBOX   Expense

  FORMCHECKBOX   Liability

  FORMCHECKBOX   Resistance from schools

  FORMCHECKBOX   Other, please specify: 

      

3.5 	EPA is interested in collecting useful lessons that Partners have
learned under SC3 and sharing them with others, e.g., at the EPA web
site.  If you have a success story that may be helpful to others, please
describe it briefly. 

  FORMTEXT        

3.6	EPA would like to collect best practices for conducting clean-outs
or other activities under SC3 and share them with others, e.g., at the
EPA web site.  If you have identified or used any best practices that
may be helpful to others, please describe them briefly.

  FORMTEXT        

3.7	EPA would like to identify ways to encourage other organizations to
join SC3.  We are interested in hearing your suggestions on methods that
we should be using.  Please describe them below.      

  FORMTEXT        

3.8	How can EPA encourage existing Partners to continue their efforts
under SC3?  (Check all that apply.)

  FORMCHECKBOX   Hold an annual awards ceremony to recognize high
achievers 

  FORMCHECKBOX   Identify Partners (e.g., by company name) on EPA web
site when they achieve specified milestones or distinctions during the
year (e.g., for “most active” Partners”)

  FORMCHECKBOX  	Issue certificate, plaque, or other item of recognition
when a Partner meets specified milestones or distinctions (e.g.,
performs a cleanout).

  FORMCHECKBOX   Help Partners find more schools to partner with.

  FORMCHECKBOX   Help Partners overcome the barrier identified in
Question 3.3.

      

3.9	Do you have any suggestions on how EPA can improve the resources
available at the SC3 web site?  Please be as specific as possible (e.g.,
identify the specific item(s) on the web site that you are referring
to).

  FORMTEXT        

 Worksheet 1:  Total Hours and Dollars Spent by Partner in Providing
Services and Resources under SC3

I.	Total Hours Spent by Your Company

Please estimate the number of hours that the employees of your company
have spent collectively in providing services and resources since
joining the Program.

Hours Spent Providing SC3 Services and Resources

  FORMCHECKBOX   Less than 100 hours

  FORMCHECKBOX   101 to 200 hours

  FORMCHECKBOX   201 to 300 hours

  FORMCHECKBOX   301 to 400 hours

  FORMCHECKBOX   401 to 500 hours

  FORMCHECKBOX   Greater than 500 hours

(please estimate a range, e.g., "600 to 700 hours”):   FORMTEXT 
       hrs to   FORMTEXT         hrs



II.	Total Expenditures of Your Company

Please estimate your company’s total expenditures in providing
services and resources since joining the Program.  You have two options
for providing this information.  Please complete Option 1 or Option 2. 
(Option 1 is preferred.)

Option 1:  For each category of expenditure, please place an “X” in
the table to indicate the range of your expenditure.  

Table of Expenditures

Categories of Expenditures

Expenditures for Materials/Supplies	Expenditures for Services 

(e.g., vendor, air travel)

  FORMCHECKBOX   Less than $1,000	  FORMCHECKBOX   Less than $1,000

  FORMCHECKBOX   $1,001-$5,000 	  FORMCHECKBOX   $1,001-$5,000 

  FORMCHECKBOX   $5,001-$10,000	  FORMCHECKBOX   $5,001-$10,000

  FORMCHECKBOX   $10,001-$15,000	  FORMCHECKBOX   $10,001-$15,000

  FORMCHECKBOX   $15,001-$20,000	  FORMCHECKBOX   $15,001-$20,000       
   

  FORMCHECKBOX   Greater than $20,000 

(please estimate a range, e.g.,“$25,000-30,000”):                   
           

       to $  FORMTEXT          	  FORMCHECKBOX  
Greater than $20,000 

(please estimate a range, e.g.,“$25,000-30,000”):                   


     $  FORMTEXT         to $  FORMTEXT        



Option 2: Please estimate the total expenditures of your company in
providing services and resources since joining the Program by placing an
“X” next to the appropriate range:

Table of Expenditures

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        to $  FORMTEXT        

Worksheet 2: Types and Quantities of Chemicals Inventoried at Schools

Since joining the SC3 Program, what types and quantities of chemicals
has your company inventoried at schools?  Please complete the table to
answer this question to the best of your ability.  If needed, you can
use ranges (e.g., “10 to 15 gallons”) and similar methods to
simplify your responses.

Note 1:  If you already have the requested information in an electronic
format that can be provided to EPA (i.e., in Microsoft Word or Excel),
you may do so.

Note 2:  Regarding chemicals for which a chemical or trade name is not
known, please complete one row of the table for all of them and
summarize any information that is known.  

Table of Chemicals Inventoried

Chemical or Trade Name of Substance Inventoried

(see material safety data sheet, if necessary)	Location of Chemical
Inventoried:

(1) Science laboratory

(2) Art classroom

(3) Vocational shop

(4) Maintenance area

(5) Other (please specify)

(6) Do not know	Age of Substance Inventoried 

(if known)	Quantity or Volume of Chemicals Inventoried

(specify units, e.g., pounds, grams, etc., if known)

      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        



Worksheet 3:  Description of Training/Education

The table below is intended for you to describe your trainings in three
ways:

Identify the training/education topics addressed;

Identify the recipients of this training/education; and

Specify the frequency of this training/education.

We realize that a Partner may provide training/education to different
types of recipients at a school across a range of training topics. 
Hence, the table below is designed for you to crosswalk specific
training topics (in the left margin) to the types of recipients that may
have received training/education in them (across the top margin).  The
shaded cells in the center of the table include a drop-down menu for you
to indicate the frequency at which you trained/educated a specific type
of recipient.

Please complete the table as follows:

1. 	Find the type(s) of recipient of your training/education in the top
margin; then,

2. 	Find the topic(s) that you trained/educated that recipient(s) in
(left margin); then,

3. 	Find their “shared” cell in the table (i.e., shaded cell) and
use the pull down menu in it to indicate the frequency of this
training/education.  

For example, if you provide training to teachers in chemical safety each
year, you would pull down the menu in the appropriate shaded cell (i.e.,
the cell in the upper left-hand corner) of the table and select
“annually.”   

Table on Training and Education

            	  FORMDROPDOWN  	  FORMDROPDOWN  	 
FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  



Worksheet 4: Types and Quantities of Chemicals Removed from Schools

Since joining the SC3 Program, what types of chemicals did your company
remove from schools?  Please complete the table to answer this question
to the best of your ability.  If needed, you can use ranges (e.g., “10
to 15 gallons”) and similar methods to simplify your responses.  Refer
to the following SC3 web address for guidance on completing the table:
TBD

Note:  If you already have the requested information in an electronic
format that can be provided to EPA (i.e., in Microsoft Word or Excel),
you may do so.

Table of Chemicals Removed From Schools

Classification of Chemicals Removed	Removed from:

(1) Science laboratory

(2) Art classroom

(3) Vocational shop

(4) Maintenance area

(5) Other (please specify)

(Simply enter the relevant numbers into the shaded cells below)	Quantity
or Volume of Chemicals Removed

(specify units, i.e. pounds, grams, etc., if known)

      	  FORMTEXT        

Ignitables, Reactives, Explosive and Oxidizers	  FORMTEXT 
      	  FORMTEXT        

Corrosives	  FORMTEXT        	  FORMTEXT        

Carcinogens and Expected Carcinogens	  FORMTEXT        	 
FORMTEXT        

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Worksheet 5:  Description of Outreach

The table below is intended for you to describe your outreach in three
ways:

Identify the types of outreach methods used;

Identify the recipients of this outreach; and

Specify the number of recipients of each type of outreach used.

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op margin).  The shaded cells in the center of the table include a
drop-down menu for you to indicate the number of recipients that
received an outreach method.

Please complete the table as follows:

1. 	Find the type(s) of outreach methods that you used in the top
margin; then,

2. 	Find the recipient(s) of that outreach in the left margin; then,

3. 	Find their “shared” cell in the table (i.e., shaded cell) and
use the pull down menu in it to indicate the number of recipients of
that outreach.  

For example, if you provided fliers to two schools, you would pull down
the menu in the appropriate shaded cell (i.e., the cell in the upper
left-hand corner) of the table and select “1 to 5”.  

Table on Outreach Efforts

      

    

Schools (K-12)	  FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  	 
FORMDROPDOWN  	  FORMDROPDOWN  

Other companies or trade associations	  FORMDROPDOWN  	  FORMDROPDOWN  	
 FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  

Community centers (e.g., YMCA)	  FORMDROPDOWN  	  FORMDROPDOWN  	 
FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  

Universities 	  FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  	 
FORMDROPDOWN  	  FORMDROPDOWN  

Local governmental organizations	  FORMDROPDOWN  	  FORMDROPDOWN  	 
FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  

General public 

      	  FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  	 
FORMDROPDOWN  	  FORMDROPDOWN  



PAPERWORK REDUCTION ACT BURDEN STATEMENT

The public reporting and recordkeeping burden for this collection of
information is estimated to range from 45 minutes to one hour 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, 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 survey to this address.

j

 OMB Control No. 20XX-XXXX

 Approval expires XX/XX/XX

 PAGE   

EPA Form No. XXXX                          **Draft May 29, 2008: Page  
PAGE  ii **

EPA Form No. XXXX                          **Draft May 29, 2008: Page  
PAGE  18 **

