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 participate in the SC3 Survey.  The survey helps us learn
about your accomplishments and the impacts being made in schools, so
this can be shared with others through tools like the SC3 Web site.  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.

We have created two survey forms, as follows:

Initial Survey.  This survey form should be completed by Partners who
are participating in the SC3 Survey for their first time.  It is
designed to give us a general idea of a Partner’s background,
accomplishments, and needs under SC3.  The survey should be completed
only for the first year of a Partner’s participation in the SC3
Program.

Annual Update.  Partners should complete an Annual Update in each
subsequent year of their partnership.  The Annual Update is designed to
describe a Partner’s accomplishments and needs since the previous
year’s survey.

Enclosed with this letter is the Annual Update.  It is organized as
follows:

Part 1 asks for general information about your company.

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 form.  If additional space is needed, please
attach additional pages.  We also would welcome any of your work
products that can be shared with others (e.g., training materials that
you developed).  



Surveys should be submitted to EPA no later than September 30th 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,

	

Matt Hale

Director, Office of Solid Waste

Enclosure

ANNUAL UPDATE:

SCHOOLS CHEMICAL CLEANOUT CAMPAIGN (SC3)

Instructions:  Please review and complete Parts 1-3 and the worksheets
of this survey.  You should complete this survey to reflect your
company’s experiences and accomplishments since September 30th of last
year (i.e., since last year’s survey).  Note that some of the
questions and worksheets may not apply to your company.  If so, please
skip them.  

Please provide your company name, the name of a contact person, and the
person’s telephone number.  In addition, indicate the date that this
survey is submitted to EPA.

      

Contact person name:   FORMTEXT        

Contact person phone number:   FORMTEXT        

Date:   FORMTEXT          

PART 1: GENERAL INFORMATION ON PARTNER

1.1	Please complete the table below to identify all schools that your
company has supported under SC3 since last year’s survey (e.g.,
support in chemical inventories, chemical management, training, etc.). 
To do so, please complete items A through C as applicable:

A.  	Please identify the school(s) by name in Column 1 of the table. 
Note: If you wish to protect the identity of the school(s), you may
assign each school a unique identifier (e.g., “School A,” “School
B,” etc.) instead of providing their names.  

B.  	For schools that are assigned a unique identifier:  Complete
Columns 2 and 3 by indicating the approximate number of students and
staff in each school.  Information on student enrollment may be
available on-line.

C.  	For schools that are assigned a unique identifier:  Indicate if you
reported the school(s) in any previous SC3 Survey by stating “Yes”
or “No” in Column 4.

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* These columns should be completed only for schools assigned a unique
identifier.

1.2	Has your company used contractors/consultants to support schools in
the following areas since last year’s survey? (Check all that apply.) 

	  FORMCHECKBOX    Chemical inventories

	  FORMCHECKBOX    Training/education

	  FORMCHECKBOX    Chemical management program

	  FORMCHECKBOX    Chemical cleanout/removal

	  FORMCHECKBOX    Outreach

      

	  FORMCHECKBOX    Contractors/consultants have not been used at all

1.3	How many hours and dollars has your company spent in providing
services and resources to schools since last year’s survey?  Please
provide your response in Worksheet 1 at the end of this survey.

1.4	Has your company encouraged other companies or associations to join
SC3 since last year’s survey?  If you select “No,” please briefly
explain why not.

	

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No 

  FORMTEXT        

1.5	Has your company encouraged schools to join SC3 since last year’s
survey?  If you select “No,” please briefly explain why not.

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No 

  FORMTEXT        

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
last year’s survey?  If you select “Yes,” please complete the
remainder of this section.  If you select “No,” skip to section 2.2.

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No

2.1.2	Please identify the schools that received support in chemical
inventories from your company since last year’s survey.  List them by
name or unique identifier (as assigned in Question 1.2) in the table
below.

      

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        



2.1.3	If any of the schools in Question 2.1.2 received support in
chemical inventories from you for the first time this survey year (i.e.,
if you did not support them in chemical inventories prior to September
30th of last year), please list them by name or unique identifier in the
table below and proceed to Question 2.1.4.  If none of the schools in
Question 2.1.2 received support in chemical inventories from you for the
first time this survey year (i.e., if you supported them in a previous
survey year), enter “none” in the table and skip to Question 2.1.5.

      

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        



2.1.4 	Were any of the schools listed in Question 2.1.3 performing
chemical inventories prior to your involvement with them?  If you select
“Yes,” please use the additional space below to describe how your
involvement improved the chemical inventories (e.g., what actions did
you take and what improvements resulted from them, such as more thorough
or frequent inventories, etc.?).

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

      

2.1.5	What chemical inventory activities has your company supported
schools in developing, implementing, and/or funding since last year’s
survey? (Check all that apply.)  Note: If you performed a walk-through
of a school and inspected for chemicals, please answer Question 2.1.6. 
If you did not, please skip to Question 2.1.7.

  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        

2.1.6	If you performed a walk-through of a school and inspected for
chemicals, which locations did you inspect? (Check all that apply.)

 

  FORMCHECKBOX   	Science laboratories

  FORMCHECKBOX   	Art classrooms

  FORMCHECKBOX   	Vocational shops

  FORMCHECKBOX   	Maintenance areas

  FORMCHECKBOX   	Cleaning closets

  FORMCHECKBOX   	Stockrooms/supply areas

      

2.1.7	What chemicals have you assisted in inventorying since last
year’s survey?  Please provide your response in Worksheet 2 at the end
of this survey.

2.1.8	If your company encountered unknown chemicals during the inventory
process identified above, what actions did you take in addressing them
during the inventory?  (Check all that apply.)

  FORMCHECKBOX    Tested unknowns 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    Did not encounter unknowns

2.2	Training and Education

2.2.1	Has your company assisted in providing training or education at a
school since last year’s survey?  If you select “Yes,” please
complete the remainder of this section.  If you select “No,” please
skip to section 2.3. 

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No

2.2.2	Please identify the schools that received training/education
support from your company since last year’s survey.  List them by name
or unique identifier (as assigned in Question 1.2) in the table below.

      

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        



2.2.3	If any of the schools in Question 2.2.2 received support in
training/education from you for the first time this survey year (i.e.,
if you did not support them in training/education prior to September
30th of last year), please list them by name or unique identifier in the
table below and proceed to Question 2.2.4.  If none of the schools in
Question 2.2.2 received support in training/education from you for the
first time this survey year (i.e., if you supported them in a previous
survey year), enter “none” in the table and skip to Question 2.2.5.

      

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        



2.2.4 	Were any of the schools listed in Question 2.2.3 performing such
training/education prior to your involvement with them?  If you select
“Yes,” please use the additional space below to describe how your
involvement improved the training/education (e.g., what actions did you
take and what improvements resulted from them, such as a greater
frequency of training, use of better training materials, coverage of new
subject matter, etc.?).

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

      

2.2.5	Please describe the training/education (e.g., recipients and
frequency of 

trainings) that you have provided since last year’s survey by
completing Worksheet 3 at the end of this survey. 

2.2.6   What types of training has your company supported schools in
developing, delivering and/or funding since last year’s survey? 
Please review the table below to see if you have supported 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        



2.2.7	Has your company assisted in developing a sustainable training
program for schools since last year’s survey (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 last year’s survey?  If you select
“Yes,” please complete the remainder of this section.  If you select
“No,” please skip to section 2.4.

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No

2.3.2	Please identify the schools that have received chemical management
program support from your company since last year’s survey.  List them
by name or unique identifier (as assigned in Question 1.2) in the table
below.

      

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        



2.3.3	If any of the schools in Question 2.3.2 received support in
chemical management from you for the first time this survey year (i.e.,
if you did not support them in chemical management prior to September
30th of last year), please list them by name or unique identifier in the
table below and proceed to Question 2.3.4.  If none of the schools in
Question 2.3.2 received support in chemical management from you for the
first time this survey year (i.e., if you supported them in a previous
survey year), enter “none” in the table and skip to Question 2.3.5.

      

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        



2.3.4 	Were any of the schools listed in Question 2.3.3 implementing a
chemical management program prior to your involvement with them?  If you
select “Yes,” please use the additional space below to describe how
your involvement improved the program (e.g., what actions did you take
and what improvements resulted from them, such as the addition of new
operating procedures or practices to address a need at the school,
etc.?).

.  

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

      

2.3.5	What elements of a chemical management program did your company
help schools to develop, implement, and/or fund since last year’s
survey?  (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    Grant writing

  FORMCHECKBOX    Use of “green cleaning” practices (e.g., using
environmentally friendly, less-toxic cleaning products)

      

2.4	Packaging, Removing and Disposing of Chemical Waste

2.4.1	Has your company assisted in packaging, removing and/or disposing
of a school’s chemical waste (i.e., chemical cleanouts) since last
year’s survey?  If you select “Yes,” please complete the remainder
of this section.  If you select “No,” please skip to section 2.5.

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No

2.4.2	Please identify the schools that have received support in chemical
cleanouts from your company since last year’s survey.  List them by
name or unique identifier (as assigned in Question 1.2) in the table
below.

      

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        



2.4.3	If any of the schools in Question 2.4.2 received support in
chemical cleanouts from you for the first time this survey year (i.e.,
if you did not support them in cleanouts prior to September 30th of last
year), please list them by name or unique identifier in the table below
and proceed to Questions 2.4.4 and 2.4.5.  If none of the schools in
Question 2.4.2 received support in chemical cleanouts from you for the
first time this survey year (i.e., if you supported them in a previous
survey year), enter “none” in the table and skip to Question 2.4.6.

      

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        



2.4.4 	Were any of the schools listed in Question 2.4.3 performing
chemical cleanouts prior to your involvement with them?  If you select
“Yes,” please use the additional space below to describe how your
involvement improved the cleanouts (e.g., what actions did you take and
what improvements resulted from them, such as more frequent or thorough
cleanouts, etc.?).

.  

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

      

2.4.5	If any of the schools in Question 2.4.3 had not performed
cleanouts on their own prior to your involvement, why not?  (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    Other, please specify:   FORMTEXT        

  FORMCHECKBOX    Not applicable

2.4.6  	What chemical cleanout activities has your company supported
schools in developing, performing, and/or funding since last year’s
survey?  (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    Other, please specify:   FORMTEXT        

2.4.7	How often have you supported these school(s) in performing
chemical cleanouts on average?

	  FORMCHECKBOX    Once

	  FORMCHECKBOX    Monthly

	  FORMCHECKBOX    Semi-annually

	  FORMCHECKBOX    Annually (e.g., at the beginning or end of the school
year)

	  FORMCHECKBOX    Other, please specify:   FORMTEXT        

2.4.8	What chemicals and other wastes have you assisted in cleaning out
since last year’s survey?  Please provide your response in Worksheet 4
at the end of the survey.     

 2.5	Outreach/Communication

2.5.1	Has your company engaged in outreach/communication in connection
with SC3 since last year’s survey (e.g., emails, phone calls, etc.)? 
If you select “Yes,” please complete the remainder of this section. 
If you select “No,” skip to Part 3. 

  FORMCHECKBOX    Yes 

  FORMCHECKBOX    No

2.5.2	What was your company’s goal(s) in performing these
outreach/communication 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 the outreach/communication efforts (e.g., types
of recipients and outreach methods) that you have performed since last
year’s survey by completing Worksheet 5 at the end of this survey.

PART 3: SUCCESSES, BARRIERS AND FUTURE ACTIVITIES

3.1	Are your company’s objectives and expectations for joining the SC3
Program being realized to your satisfaction?  If you select “No,”
please briefly explain why not.

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No 

  FORMTEXT        

3.2	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

      

3.3 	EPA is interested in collecting useful lessons that Partners have
learned under SC3 and sharing them with others, e.g., at the SC3 Web
site.  If you have a success story that may be helpful to others, please
describe it briefly (e.g., can you describe a situation in which you
cleaned out a school's wastes and thereby avoided a potentially
dangerous situation for students and/or faculty?). 

  FORMTEXT        

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

  FORMTEXT        

3.5	Do you have any suggestions on how EPA can improve the resources
available at the SC3 Web site?  Please be as specific as possible.

  FORMTEXT        

 Worksheet 1:  Total Hours and Dollars Spent by Partner in Providing
Services and Resources under SC3 Since Last Year’s Survey

Please complete Sections I through III of this worksheet to reflect your
company’s hours and dollars spent under SC3 since last year’s
survey.

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 under SC3
since last year’s survey.

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 under SC3 since last year’s survey.  For each
category of expenditure, please place an “X” in the table to
indicate the range of your expenditure.  

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        



Expenditures for Cleanouts

Please indicate the percentage of your expenditures estimated in Section
II, above, that went towards chemical cleanouts.  (Check only one box.) 
 Note:  The percentage that you provide below should be based on the
total expenditures provided in the second column of the Table in Section
II (see the column “Expenditures for Services”).  

  FORMCHECKBOX    0% (i.e., you did not make any expenditures for
cleanouts)

  FORMCHECKBOX    1-10%   

  FORMCHECKBOX    11-20%

  FORMCHECKBOX    21-30%

  FORMCHECKBOX    31-40%

  FORMCHECKBOX    41-50%

  FORMCHECKBOX    Greater than 50%; please specify a range:   FORMTEXT 
      

Worksheet 2: Types and Quantities of Chemicals Inventoried at Schools

Since last year’s survey, 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 response.

Note 1:  If you already have the requested information in an electronic
format, you may e-mail it to EPA, along with your survey responses.  You
do not need to complete the table below.

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* 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)	Age of Substance Inventoried 

(if known)	Quantity or Volume of Chemicals Inventoried

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



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Worksheet 3:  Description of Training/Education

Please complete the table below by describing the training/education
that you have supported at schools since last year’s survey.  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 cell in the upper left-hand
corner of the table and select “annually.”

Table on Training and Education

Training Topics

 	Types of Recipients of Training/Education

	 Teachers	Maintenance/ building personnel	School administrators
Students	Other, please specify:  FORMTEXT            

Chemical safety	  FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  	 
FORMDROPDOWN  	  FORMDROPDOWN  

Emergency response 	  FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  	 
FORMDROPDOWN  	  FORMDROPDOWN  

Regulatory compliance 	  FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN 
	  FORMDROPDOWN  	  FORMDROPDOWN  

Proper chemical management 	  FORMDROPDOWN  	  FORMDROPDOWN  	 
FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  

Proper waste management 	  FORMDROPDOWN  	  FORMDROPDOWN  	 
FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  

Other, please specify:   FORMTEXT              	 
FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  	  FORMDROPDOWN  	 
FORMDROPDOWN  



Worksheet 4: Types and Quantities of Wastes Removed from Schools

Since last year’s survey, what types and quantities of chemicals and
other wastes has your company helped to remove from schools?  You have
two options for providing this information.  Please complete Option 1 or
Option 2. 

Option 1:  Refer to the table on the next page to learn the information
we are requesting and see if you already have this information in an
existing format (e.g., a paper copy of a hazardous waste manifest or
shipping paper, an electronic file such as a MS Excel spreadsheet,
etc.).  If you do, you may submit this information instead of completing
Option 2. 

Option 2:  Please complete the table on the next page by describing the
chemicals and other wastes you have removed from schools since last
year’s survey.  The table is designed to be as flexible as possible,
as we realize that Partners will have varying levels of information
about the wastes removed.  At the bottom of this page, we provide some
examples on how wastes can be summarized in the table.  

Notes:

In Waste Description column: describe the wastes removed.  Be sure to
mention chemical names and other descriptive information (e.g., solid,
liquid or gas) if known.  You may aggregate the following onto one row
of the table 1) all “unknown wastes”; and 2) all lab packs (please
specify one or a few of the predominant chemicals in the lab pack
waste).  See examples.

In Quantity or Volume column: estimate the total quantity (weight) or
volume of the waste and specify units.  If you are uncertain of the
quantity or volume, specify a range (e.g., “less than 10 pounds”).

In Properties column: check all of the properties that you know of
regarding the wastes.  If needed, specify another property.  See
example.

Table of Wastes Removed (Example)

Waste Description	Quantity or Volume (specify units)	Properties (Check
all that apply)



Toxic, Poisonous,  Generally Harmful	Ignitable/

Flammable	Acid or Base	Reactive/

Explosive	Other (please specify)	Not Harmful	Don’t Know

Approx 5 bottles of old cleaning detergent (liquid)	  FORMTEXT  < 1 gal.
	  FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  	 
FORMTEXT  Irritant if in contact with skin 	  FORMCHECKBOX  	 
FORMCHECKBOX  

Unknown chemicals in various containers (liquids, solids)	  FORMTEXT 
20-30 lbs. 	  FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  	 
FORMCHECKBOX  	  FORMTEXT        	  FORMCHECKBOX  	 
FORMCHECKBOX  

Approx 40 thermometers in boxes - liquid mercury	  FORMTEXT  < 1lb.
     	  FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  	 
FORMCHECKBOX  	  FORMTEXT        	  FORMCHECKBOX  	 
FORMCHECKBOX  

Misc classroom items in boxes – solids (e.g., chalk, erasers)	 
FORMTEXT  < 10 lbs. 	  FORMCHECKBOX  	  FORMCHECKBOX  	  FORMCHECKBOX  	
 FORMCHECKBOX  	  FORMTEXT        	  FORMCHECKBOX  	 
FORMCHECKBOX  

Lab packs – liquids, solids (acetone, toluene, barium)

	  FORMTEXT  3 20-gallon lab packs 	  FORMCHECKBOX  	  FORMCHECKBOX  	 
FORMCHECKBOX  	  FORMCHECKBOX  	  FORMTEXT        	 
FORMCHECKBOX  	  FORMCHECKBOX  



Table of Wastes Removed

Waste Description	Quantity or Volume (specify units)	Properties (Check
all that apply)



Toxic, Poisonous,  Generally Harmful	Ignitable/

Flammable	Acid or Base	Reactive/

Explosive	Other (please specify)	Not Harmful	Don’t Know

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Worksheet 5:  Description of Outreach/Communication Related to SC3

Please complete the table below by describing the outreach/communication
efforts that you have performed related to SC3 since last year’s
survey.  The table is designed for you to select the types of
outreach/communication methods that you have used and to indicate the
number and types of recipients of that outreach/communication.

Please complete the table as follows:

1. 	Find the type(s) of outreach/communication methods that you have
used in regard to SC3 in the left hand column; then,

2. 	Select the approximate number of recipients who received that
outreach/communication in the second column of the table (numbers are
presented as ranges); then,

3. 	Select the type of recipient of that outreach/communication in the
third column.

For example, if you made a presentation on SC3 at a conference and about
200 people attended, you would complete Row 3 of the table by selecting
“151-200” in the second column and “Individuals” in the third. 
For some types of outreach in the table, a suggestion is provided on how
to estimate the number of outreach recipients.  

Number and Type of Outreach/Communication Recipients 

Types of Outreach/Communication Related to SC3

 	Recipients

	Approximate Number of Recipients	Types of 

Recipients

1. Hand-outs and mailed items (e.g., fliers, brochures, etc.)	 
FORMDROPDOWN  	  FORMDROPDOWN  

2. Emails and/or other electronic distribution methods used to inform
recipients of SC3-related issues/topics	  FORMDROPDOWN  	  FORMDROPDOWN 


3. Conferences, seminars, teleconferences, etc. at which you discussed
information related to SC3 	  FORMDROPDOWN  	  FORMDROPDOWN  

4. Public service announcement(s) 	  FORMDROPDOWN  	  FORMDROPDOWN  

5. Article(s) in a newsletter, journal, etc. (Note:  You may estimate
the number of “outreach recipients” based on the circulation of the
newsletter or journal, if known)	  FORMDROPDOWN  	  FORMDROPDOWN  

6.  Information on your Web site (Note: You may estimate the number of
“outreach recipients” based on the number of “hits” at the Web
page after the information was posted)	  FORMDROPDOWN  	  FORMDROPDOWN  

7. Other, please specify:   FORMTEXT        	  FORMDROPDOWN  	
 FORMDROPDOWN  



PAPERWORK REDUCTION ACT BURDEN STATEMENT

The public reporting and recordkeeping burden for this collection of
information is estimated to be 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, 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.

 OMB Control No. 2050-XXXX

 Approval expires XX/XX/XX

 PAGE   

EPA Form No. 6200-06                         September 5, 2008: Page  
PAGE  i 

EPA Form No. 6200-06                          September 5, 2008: Page  
PAGE  12 

