              What Do You Think About the U.S. EPA's Community 
                  Involvement Efforts at the ________   Site?
                                       
--------------------------------------------------------------------------------
Purpose for this Questionnaire: This customer satisfaction survey is meant to help understand how well EPA staff are listening to community member concerns about the cleanup and how well EPA staff make it possible for community members to participate in the planning and decision making process. 
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Instructions:  You may be asked some of the questions on this questionnaire. This questionnaire should take no more than 15 minutes to complete, and responses are voluntary.

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Burden Statement:  The public reporting and recordkeeping burden for this collection of information is estimated to average 15 minutes per response. An agency may not conduct a collection of information without a valid OMB control number. The OMB control number for this collection is OMB 2050-0179. 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.  

      The U.S. Environmental Protection Agency (U.S. EPA) is cleaning up the contamination at the __________ Superfund site in your community.  The U.S. EPA believes the active, meaningful involvement of community members is critical to the success of a cleanup effort.  This survey is an opportunity for you to tell us how well we are doing at listening to your concerns about the cleanup and making it possible for you to participate in the planning and decision making process.  Please take a few minutes to answer the questions.  Your views are important and will help us to be more responsive to your needs and interests.  

      This survey is being conducted in accordance with the Federal Paperwork Reduction Act Information Collection Request # 1487.13.  You will need about 15 minutes to answer the questions.

*Note to surveyors: It is intended that each survey given will include the introductory paragraph, above, and Section G with the closing disclosure.  Sections A-F are optional sections with questions that may be used as a specific situation dictates.  This survey is NOT intended to be given in its entirety. The surveyor may also choose, in addition to paper copies, to provide the survey to participants online via commercially available software.











Section A:	Assessing Overall U.S. EPA Community Involvement Efforts

A-1.	How do you rate the U.S. EPA at each of the following?   (Circle one choice for each question)

 Providing the information you need.
                                   Very Poor
                                     Poor
                                    Average
                                     Good
                                   Very Good
 Making the information easy to understand.
                                   Very Poor
                                     Poor
                                    Average
                                     Good
                                   Very Good
 Making it easy to get involved.
                                   Very Poor
                                     Poor
                                    Average
                                     Good
                                   Very Good
 Listening to your concerns.
                                   Very Poor
                                     Poor
                                    Average
                                     Good
                                   Very Good
 Responding to your concerns.
                                   Very Poor
                                     Poor
                                    Average
                                     Good
                                   Very Good
 Treating you courteously.
                                   Very Poor
                                     Poor
                                    Average
                                     Good
                                   Very Good
 Using your input.
                                   Very Poor
                                     Poor
                                    Average
                                     Good
                                   Very Good
 Explaining decisions.
                                   Very Poor
                                     Poor
                                    Average
                                     Good
                                   Very Good

Section B:	Assessing U.S. EPA Efforts at Keeping Communities Informed

B-1.  	How do you learn about the U.S. EPA's work at the site? (Check all that apply)

_____
U.S. EPA mailings
_____
Newspaper articles
_____
Radio or TV news
_____
U.S. EPA's web page
_____
Community members/family/friends
_____
Public meeting or information session held by the U.S. EPA
_____
Direct conversation with someone from the U.S. EPA
_____
Information about the site is "common knowledge"
_____
Know someone who worked at the site
_____
Through one or more community organizations, business associations, or advisory groups (CAG)
_____
Social Media (Facebook, Twitter, etc.)
_____
Other (Please specify): ____________________________________________________________


B-2.	How would you prefer to receive information from the U.S. EPA about the site?  
      (Check up to 3 choices)

_____
Mailings -- short (1-2 pages) very focused (issue-specific) sent frequently
_____
Mailings -- longer, general information, sent periodically
_____
Emails -- brief, very focused (issue-specific) sent frequently
_____
Emails -- longer, general information, sent periodically
_____
Meetings -- short, very focused, held frequently
_____
Meetings -- longer, general informational meetings, held periodically
_____
Social media (Facebook, Twitter)
_____
Direct communication with an U.S. EPA representative
_____
The U.S. EPA website
_____
Presentations at local clubs and organizations
_____
Other (Please specify): ____________________________________________________________
B-3.  	How interested are you in obtaining information about the following topics?  (Circle one answer for each question)

 U.S. EPA's Superfund Program.
                                Not Interested
                              Somewhat Interested
                                  Interested
                                Very Interested
 Contamination at the site.
                                Not Interested
                              Somewhat Interested
                                  Interested
                                Very Interested
 How the site might affect human health.
                                Not Interested
                              Somewhat Interested
                                  Interested
                                Very Interested
 How the site might affect the environment.
                                Not Interested
                              Somewhat Interested
                                  Interested
                                Very Interested
 Site cleanup decisions.
                                Not Interested
                              Somewhat Interested
                                  Interested
                                Very Interested
 Site reuse or redevelopment.
                                Not Interested
                              Somewhat Interested
                                  Interested
                                Very Interested
 Other (Please specify):_____________
                                Not Interested
                              Somewhat Interested
                                  Interested
                                Very Interested

B-4. 	In what ways do you prefer to participate at this site? (Check all that apply)

_____
Through opportunities to provide written comments on U.S. EPA documents.
_____
Through public meetings.
_____
Through opportunities to meet and talk informally with U.S. EPA staff.
_____
By attending community club/organization meetings that U.S. EPA staff have been invited to.
_____
By calling a toll-free telephone number.
_____
Through a community group.
_____
Through opportunities to talk with independent experts.
_____
Through a web site or social media.
_____
Other (Please specify): ___________________________________________________________
_____
Not interested in being involved.

B-5.	Please tell us whether you have ever:
 Provided information to the U.S. EPA about the site and its history.
Yes
No
 Expressed your concerns about the site to the U.S. EPA.
Yes
No
 Offered suggestions or advice about the site to the U.S. EPA.
Yes
No
 Given comments to the U.S. EPA on materials available for public review.
Yes
No
 Requested information from the U.S. EPA about the site.
Yes
No
 Attended a U.S. EPA-sponsored meeting or event about the site.
Yes
No
 Visited the site's information repository.
Yes
No






B-6. 	In a few words, what is your understanding of the cleanup work U.S. EPA plans to do at the site? 

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
B-7.	How concerned are you that the site may be harmful to each of the following: (Circle one answer for each question.)

  My or my family's health.
                                      Not
                                   Concerned
                                   Somewhat
                                   Concerned
                                   Concerned
                                     Very
                                   Concerned
                                Not Applicable
  The environment. 
                                      Not
                                   Concerned
                                   Somewhat
                                   Concerned
                                   Concerned
                                     Very
                                   Concerned
                                Not Applicable
  Property values. 
                                      Not
                                   Concerned
                                   Somewhat
                                   Concerned
                                   Concerned
                                     Very
                                   Concerned
                                Not Applicable
  Jobs in the community.
                                      Not
                                   Concerned
                                   Somewhat
                                   Concerned
                                   Concerned
                                     Very
                                   Concerned
                                Not Applicable
  Business in the community.
                                      Not
                                   Concerned
                                   Somewhat
                                   Concerned
                                   Concerned
                                     Very
                                   Concerned
                                Not Applicable
  Community historical or cultural integrity.
                                      Not
                                   Concerned
                                   Somewhat
                                   Concerned
                                   Concerned
                                     Very
                                   Concerned
                                Not Applicable
  Site redevelopment or reuse.
                                      Not
                                   Concerned
                                   Somewhat
                                   Concerned
                                   Concerned
                                     Very
                                   Concerned
                                Not Applicable





















Section C:	Public Meeting Feedback Questions

These questions will help the U.S. EPA better understand what worked well and what improvements to consider making before holding future public meetings.

C-1.	How did you learn about this public meeting? (Check all that apply)

_____
U.S. EPA mailings (other than this survey)
_____
Newspaper articles
_____
Radio or TV news
_____
Community organization
_____
Family or friends
_____
Email from U.S. EPA 
_____
U.S. EPA's website
_____
Social media (Facebook, Twitter, etc.)
_____
Flyers in store windows/bulletin boards
_____
Direct conversation with someone from the U.S. EPA
_____
Other (Please specify): ___________________________________________________________

C-2.	Please give us your feedback on the following:  (Circle one choice for each question)

a. 	Information about the meeting was available early enough to make plans to attend.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                Strongly Agree
b.	Meeting location was convenient.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                Strongly Agree
c.	Meeting facility was comfortable.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                Strongly Agree
d.	Meeting time was convenient.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                Strongly Agree
e.	The length of the meeting was appropriate.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                Strongly Agree
f.	Language interpreters were available 
    (if needed).
                               Strongly Disagree
                                   Disagree
                                     Agree
                                Strongly Agree
g.  Provisions were made to accommodate the needs of persons with disabilities
                               Strongly Disagree
                                   Disagree
                                     Agree
                                Strongly Agree
 Meeting facility was well-equipped for all planned activities (enough seats, work space, supplies, etc.).
                               Strongly Disagree
                                   Disagree
                                     Agree
                                Strongly Agree


C-3.   What topics were of most interest to you at the meeting?
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________

C-4.   How was the meeting useful to you? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________

C-5.   How can U.S. EPA improve the next public meeting?
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________

Section D:	Questions for Use During Site Cleanup-Removal/Relocation 

These questions will help the U.S. EPA better understand what worked well and what improvements to consider when implementing future removals requiring temporary relocation of residents.

Introduction: You were recently relocated while removal and restoration activities were completed at your property.  These activities were designed to remove significant potential sources of _[contaminant]_ from your property, thereby reducing any potential _[contaminant]_-related health exposures.  We would appreciate it if you could take a few moments to provide feedback on your relocation experience and the removal/restoration work that was completed on your property.

D-1.   Relocation  (Circle one choice for each question)

a. 	U.S. EPA staff were friendly and helpful.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
b.	The relocation handouts I was given were useful and understandable.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
c.	U.S. EPA staff responded to my questions in a timely manner.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
d.	I was treated with courtesy and respect by U.S. EPA staff.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
e.	U.S. EPA staff contacted me as often as I would have liked:
                                       
                                       
                                       
                                       

   Before my relocation.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
   While I was relocated.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
   After my property was cleaned up and I was back in my home.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
f.	I was well-informed of my choices for relocation (hotel, friend's home, etc.).
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
g.	I was well-informed about the expected length of my relocation and was kept informed of any changes.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
h.	I was told when I needed to relocate with enough time to plan my move.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
i.	The reimbursement paperwork was understandable.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
j.	I received my reimbursement within 30 days.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
D-2.	U.S. EPA's Work on My Property: Removal and Restoration (Circle one choice for each question)

a.	I was well-informed about the extent of the work U.S. EPA would do on my property.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
b.	The specifics of the property restoration were explained in writing and provided to me.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
c.	I was informed of the landscape options for my property.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
d.	I understood what I had to do following the removal at my property in order for the landscaping to be successful.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
e.	The on-site workers were courteous and respectful.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
f.	I was kept informed about any changes in the schedule for the work on my property.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
g.	I was informed if any of my possessions could NOT be decontaminated.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
h. 	My property was restored to a condition at least equal to its previous condition (recognizing that it may take time and water/aerating on my part for the seed to take or plants to grow).
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable
i.	The work done on my property met my expectations.
                               Strongly Disagree
                                   Disagree
                                     Agree
                                   Strongly
                                     Agree
                                Not Applicable

D-3.	Do you have any additional comments/feedback regarding your relocation or the removal/restoration work on your property? (Use the space below) 

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
_________________________________________________________________________________

Section E:	 Questions for Use at Sites with Institutional Controls  

These questions will help the U.S. EPA better understand whether community members are aware of, or interested in, information about any institutional controls (ICs) at the site - , which are administrative and legal controls, including limitations on land use or resource use, deed restrictions, or building codes. An example of an IC might be building code restrictions to prevent vapor intrusion, or preventing development on a landfill cap to avoid damage to the integrity of the cap surface. Community input can be essential to selecting, using, and monitoring ICs that are the best fit for the community and the protectiveness of the remedy.

E-1.	Are you aware of any restrictions (institutional controls) in place at the site including limitations on land and/or resource use, building code requirements or deed restrictions? 
       ___Yes 	 ___ No

E-2.	Would you like more information about restrictions (institutional controls) on the use of land or resources or any deed restrictions in place at the site?
      ___Yes	 ___ No

If yes, please contact  (Name and phone number) to request the information.
















Section F:	Questions about Technical Assistance Resources Provided to the Community 

These questions will help the U.S. EPA better understand how to provide the most effective technical assistance resources at sites.

F-1.	Do you know of any assistance U.S. EPA has provided to help you and other community members/groups better understand technical and scientific information regarding the site cleanup?

       ____Yes     	 _____No   (Please skip to question F-3)      
 

F-2.  How was technical assistance provided to your community? (check all that apply)
____
Through a Technical Assistance Grant (TAG)
____
Through Technical Assistance Services for Communities (TASC)
____
Through U.S. EPA site staff
____
Through assistance from a local, regional or national organization/entity/university
____
Through a Pediatric Environmental Health Specialty Unit (PEHSU)
____
Through a Technical Assistance Plan (TAP)
____
Through Technical Assistance for Public Participation (TAPP)
____
I do not know how the assistance was provided
____
Other (Please specify):__________________________________________________________















Please rate how useful each of the following has been in helping community members better understand information about the site and take a more active role in the process: 
   
 a.	Community informational newsletters and/or factsheets.
                                  Not Helpful
                               Somewhat Helpful
                                    Helpful
                                 Very Helpful
                                Not Applicable
 b. 	Presentations by experts to explain technical site information to the community.
                                  Not Helpful
                               Somewhat Helpful
                                    Helpful
                                 Very Helpful
                                Not Applicable
 c.	Community informational workshops/trainings.
                                  Not Helpful
                               Somewhat Helpful
                                    Helpful
                                 Very Helpful
                                Not Applicable
 d.	Redevelopment planning.
                                  Not Helpful
                               Somewhat Helpful
                                    Helpful
                                 Very Helpful
                                Not Applicable
 e.	U.S. EPA provides facilitator or mediator to help the community.
                                  Not Helpful
                               Somewhat Helpful
                                    Helpful
                                 Very Helpful
                                Not Applicable
 f.	U.S. EPA assists community groups that want to help the community understand or participate in the site cleanup process. 
                                  Not Helpful
                               Somewhat Helpful
                                    Helpful
                                 Very Helpful
                                Not Applicable
 g.	Other (Please specify):  ___________________________
                                  Not Helpful
                               Somewhat Helpful
                                    Helpful
                                 Very Helpful
                                Not Applicable



F-3. 	If technical assistance has not been provided to your community, which of the following activities could help you and other community members/groups better understand technical and scientific information regarding the site cleanup? (Check all that apply)

____
Community informational newsletters and/or factsheets.
____
Presentations by experts to explain technical site information to the community.
____
Community informational workshops/trainings.
____
Redevelopment planning.
____
U.S. EPA provided facilitator or mediator to help the community.
____
U.S. EPA gave assistance to one or more community groups that wanted to help the community understand or participate more actively in the site cleanup process.
____
Other (Please specify):__________________________________________________________
____
I don't feel that any technical assistance is needed.
   


Section G: 	General Information [REQUIRED Section]

This section must be included at the end of all surveys.

G-1.	Is there anything else you would like to tell us about the U. S. EPA's community involvement efforts or about the cleanup activities at this site?

__________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________



Thank you for taking the time to share your views with us. If you would like to be on the U.S. EPA's mailing list, please contact (Name, Telephone Number).







