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OMB Control No: 2050-0179

Expiration Date xx/xx/xxxx

What Do You Think About the U.S. EPA’s Community 

Involvement Efforts at the ________ Site?

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 # 1487.11. 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)

a. Providing the information you need. Very 

Poor Poor Average Good Very Good

b. Making the information easy to 

understand.

Very 

Poor Poor Average Good Very Good

c. Making it easy to get involved.

Very 

Poor Poor Average Good Very Good

d. Listening to your concerns. Very 

Poor Poor Average Good Very Good

e. Responding to your concerns. Very 

Poor Poor Average Good Very Good

f. Treating you courteously. Very 

Poor Poor Average Good Very Good

g. Using your input. Very 

Poor Poor Average Good Very Good

h. Explaining decisions. Very 

Poor Poor Average Good Very Good
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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): ____________________________________________________________
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B-3. How interested are you in obtaining information about the following topics? (Circle one 

answer for each question)

a. U.S. EPA’s Superfund Program.

Not 

Interested

Somewhat

Interested Interested Very Interested

b. Contamination at the site. Not 

Interested

Somewhat 

Interested Interested Very Interested

c. How the site might affect human health. Not 

Interested

Somewhat 

Interested Interested Very Interested

d. How the site might affect the environment. Not 

Interested

Somewhat 

Interested Interested Very Interested

e. Site cleanup decisions. Not 

Interested

Somewhat 

Interested Interested Very Interested

f. Site reuse or redevelopment. Not 

Interested

Somewhat 

Interested Interested Very Interested

g. 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:

a. Provided information to the U.S. EPA about the site and its history. Yes No

b. Expressed your concerns about the site to the U.S. EPA. Yes No

c. Offered suggestions or advice about the site to the U.S. EPA. Yes No

d. Given comments to the U.S. EPA on materials available for public review. Yes No

e. Requested information from the U.S. EPA about the site. Yes No

f. Attended a U.S. EPA-sponsored meeting or event about the site. Yes No

g. 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? 

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________
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B-7. How concerned are you that the site may be harmful to each of the following: (Circle one 

answer for each question.)

a. My or my family’s health.

Not

Concerned

Somewhat

Concerned Concerned VeryConcerned

Not 

Applicable

b. The environment.

Not

Concerned

Somewhat

Concerned

Concerned Very

Concerned

Not 

Applicable

c. Property values.

Not

Concerned

Somewhat

Concerned

Concerned Very

Concerned

Not 

Applicable

d. Jobs in the community.

Not

Concerned

Somewhat

Concerned

Concerned Very

Concerned

Not 

Applicable

e. Business in the community.

Not

Concerned

Somewhat

Concerned

Concerned Very

Concerned

Not 

Applicable

f. Community historical or 

cultural integrity.

Not

Concerned

Somewhat

Concerned

Concerned Very

Concerned

Not 

Applicable

g. Site redevelopment or reuse. Not

Concerned

Somewhat

Concerned

Concerned Very

Concerned

Not 

Applicable
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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

h. Meeting facility was well-equipped for all 

planned activities (enough seats, work 

space, supplies, etc.).

Strongly 

Disagree Disagree Agree Strongly Agree

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.
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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?

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________
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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 StronglyAgree

Not 

Applicable

b. The relocation handouts I was given 

were useful and understandable.

Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

c. U.S. EPA staff responded to my 

questions in a timely manner.

Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

d. I was treated with courtesy and respect 

by U.S. EPA staff.

Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

e. U.S. EPA staff contacted me as often as I 

would have liked:

 Before my relocation. Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

 While I was relocated. Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

 After my property was cleaned up and 

I was back in my home.

Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

f. I was well-informed of my choices for 

relocation (hotel, friend’s home, etc.).

Strongly 

Disagree Disagree Agree StronglyAgree

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 StronglyAgree

Not 

Applicable

h. I was told when I needed to relocate with 

enough time to plan my move.

Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

i. The reimbursement paperwork was 

understandable.

Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

j. I received my reimbursement within 30

days.

Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

D-2. U.S. EPA’s Work on My Property: Removal and Restoration (Circle one choice for each 

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.
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question)

a. I was well-informed about the extent 

of the work U.S. EPA would do on 

my property.

Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

b. The specifics of the property 

restoration were explained in writing 

and provided to me.

Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

c. I was informed of the landscape 

options for my property.

Strongly 

Disagree Disagree Agree StronglyAgree

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 StronglyAgree

Not 

Applicable

e. The on-site workers were courteous 

and respectful.

Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

f. I was kept informed about any 

changes in the schedule for the work 

on my property.

Strongly 

Disagree Disagree Agree StronglyAgree

Not 

Applicable

g. I was informed if any of my 

possessions could NOT be 

decontaminated.

Strongly 

Disagree Disagree Agree StronglyAgree

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 StronglyAgree

Not 

Applicable

i. The work done on my property met 

my expectations.

Strongly 

Disagree Disagree Agree StronglyAgree

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)

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________
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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.
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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):__________________________________________________________
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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 VeryHelpful

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.
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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).

The public reporting and recordkeeping burden for this collection of information is estimated to average 15 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.