ATSDR Community Activities Survey - Telephone

ATSDR Communication Activities Survey (ACAS)

AttF3 Telephone ACAS 20170612 clean

Community Members - ACAS Telephone

OMB: 0923-0055

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ATTACHMENT F3. Telephone ACAS

ACAS Phone Script

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Form Approved

OMB No. 0923-XXXX

Exp. Date MM/DD/YYYY

SURVEY ID |____|____|____|____|____|

[Interviewer reads…] Hello, my name is ______________________________________ [Please specify Interviewer Name and Title]. I am calling you today on behalf of the Agency for Toxic Substances and Disease Registry (ATSDR). Recently you attended a community meeting and agreed to take a survey that would help us improve our services in your community. Thank you for that! We are interested in getting your feedback on how effective and timely ATSDR is in informing communities.

The information will be used to help ATSDR improve what we do in a way that’s best for community members and local and state agency stakeholders. The survey results will be used by ATSDR to provide valuable health information so that you can protect yourself, your family, and your community from environmental health risks.

[Interviewer] Would you like to participate in the survey now? It will only take about 15 minutes.

____ Yes Continue with the survey [Read consent, below]

____ No Do you prefer that we call you back at another time?

[Specify date/time/phone # preference on contact info]


[If they changed their mind, and don’t want to participate anymore,

End Call]

Thank you very much for your time. Have a great day/evening]!

[Only if person is a community member, read the following . . .] Community members will be mailed a $5 gift card after completing this survey.

[Interviewer reads…]

Providing your contact information and taking part in this survey is completely voluntary. You may skip any question or stop at any time. Your responses and identity will be kept private to the extent allowed by law. Digital data will be stored in secure computer files. We will not release your identity in any ATSDR reports. Please be sure to get all of your questions about the survey answered by ATSDR before you begin.

By proceeding, you indicate that you are 18 years of age or older, and CONSENT to participate in this survey.

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ATSDR estimates the average public reporting burden for this collection of information as 15 minutes per survey, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).

[Interviewer begins the survey by asking the following questions – Are you ready to begin? Let’s begin!]

In the first section, I’ll ask questions related to your involvement with the activities ATSDR has conducted in your community. First question…

Your Involvement with Site Activities

  1. Before this public meeting, when did you first find out about the environmental risk(s) at (insert name of site here)_________________________________________________?

1 I didn’t know about it before this meeting

2 I don’t remember

3 Specify Month and Date or Approximate time of year (e.g., Summer 2015)____________________


  1. How did you first hear about the environmental risk(s) at this site?

Check ALL That Apply


1 Mailing (e.g., letter, report, flyer, sent to libraries, Health Departments, grocery stores, government facilities, county office, etc.)

2 Newspaper Advertisement

3 Email

4 TV/Radio (e.g., Public Service Announcement Ads)

5 Community Meeting

6 Official Government informational Meeting

7 Neighbor or Friend

8 I don’t remember

9 Other (e.g., social media, Twitter, Facebook, etc.) Specify:______________________________



  1. Do you live or work near the environmental risk(s)?

Choose ALL That Apply from the list I’m about to read…


1 I live near the environmental site

2 I work near the environmental site

3 I live AND work near the environmental site

4 I do not live OR work near the environmental site









The next set of questions will test your knowledge about ATSDR activities…

Your Knowledge of Site Activities



  1. Do you know why ATSDR is at this site? Choose One Answer from the list I’m about to read…

1 Determine if there is a harmful environmental risk at this site

2 Clean up the environmental risk(s) at this site

3 Give medical treatment and healthcare services

4 Enforce laws and guidelines

5 Don’t know


  1. What do you know about the environmental risk(s) at this site now? Choose One Answer…

1 It is an environmental risk but it does NOT pose a risk to human health

2 It is an environmental risk and it DOES pose a risk to human health

3 It was an environmental risk but it does NOT pose a risk to human health now

4 It was an environmental risk and it DOES still pose a risk to human health

5 None of the above


  1. Has ATSDR helped you to better understand the environmental risk(s) at this site?

1 Yes

2 No

3 Some, But Not All

4 Don’t know


  1. Do you know if you or your family have come in contact with environmental risk(s)?

1 Yes

2 No

3 Don’t know


  1. Before ATSDR (or your State or Local Agency) came to your community, did you know what you and your family should do to avoid contact with the environmental risk(s) at the site?

1 Yes

2 No

3 Don’t know




  1. Since ATSDR came into your community, do you NOW know more about what you and your family should do to avoid contact with the environmental risk(s) at the site?

1 Yes

2 No

3 Don’t know


  1. If you have questions, do you know who to contact in ATSDR (or in your State or Local Agency)?

1 Yes

2 No

3 Don’t know



The next 2 questions are about your observations and opinions about ATSDR...

Your Observations and Opinions about ATSDR

  1. Do you think ATSDR understands your health concerns related to the environmental risks(s) at this site?

1 Yes

2 No

3 Some, but not all

4 Don’t know


  1. Do you think ATSDR has given you all the information you need to address your health concerns related to the environmental risk(s) at this site?

1 Yes

2 No

3 Some, but not all

4 Don’t know







Ok now, give me your observations about your community [Interviewer leads right into the question……]



Your Observations and Opinions about Your Community

  1. After ATSDR’s work has finished, do you think your community will be better prepared to handle environmental risk(s) at this site?

1 Yes

2 No

3 Some, but not all

4 Don’t know



Self-evaluation Questions

  1. The following questions will ask about your feelings or emotions, or how you feel right now about your risk of exposure to the environmental risk(s) at this site? I will read to you eleven (11) different types of emotions… and, you will tell me whether you feel LESS, the SAME, or MORE for each emotion right now.

For each emotion, CHOOSE ONE answer to tell us how you feel right now.

EMOTION

I feel LESS of this emotion

I feel the SAME amount of this emotion

I feel MORE of this emotion

  1. STRESSED




  1. SATISFIED




  1. ANGRY




  1. CONTENTED




  1. WORRIED




  1. PLEASED




  1. FRUSTRATED




  1. AT EASE




  1. DISGUSTED




  1. HOPEFUL




  1. SCARED





And finally, in this last section, you get to tell me a little ABOUT YOU. These questions are just to help us know a little bit about the people who live in this community.

About You


  1. How long have you lived at your current address? Choose ONE Answer

1 Less than 1 month

2 At least 1 month but less than 1 year

3 At least 1 year but less than 5 years

4 At least 5 years or more


  1. How many children under 18 years old live with you? Choose ONE Answer

1 None

2 1

3 2

4 3

5 4+






  1. What is the highest grade or level of school you completed? Choose ONE Answer

1 8th grade or less

2 Some high school, but did not graduate

3 High school graduate or GED

4 Some college or 2-year degree

5 4-year college graduate

6 More than a 4-year college degree

7 None of the Above


  1. Do you consider yourself to be Hispanic or Latino? Choose ONE Answer

1 Hispanic or Latino

2 Not Hispanic or Latino



  1. What race or races do you consider yourself to be? Choose ALL that Apply from the list I’m about to read…

1 American Indian or Alaskan Native

2 Asian

3 Black or African American

4 Native Hawaiian or Other Pacific Islander

5 White




  1. How old are you? Choose ONE Answer

1 18 to 24

2 25 to 34

3 35 to 44

4 45 to 54

5 55 to 64

6 65 to 74

7 75 or older



  1. Are you male or female? Choose ONE Answer

1 Male

2 Female





We’re about to wrap up now, but before we do, I’d like to ask you 2 questions related to this survey…

Response to the Survey



  1. Do you have any concerns about anything else related to possible environmental risk(s) in your community that the survey did not ask? [Probe]

1 Yes

2 No

If Yes, what are your concerns?:_________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________



  1. Do you have any other feedback? [if Yes, Probe]

1 Yes

2 No

If Yes, give me your feedback:____________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________



[Interviewer reads…] This concludes the survey. I would like to thank you for your participation. Your feedback will help us improve our work in a way that’s best for you and your community.

[Only if person is a community member, continue . . . ] Now that you’ve completed the survey we will mail you a $5 gift card to the address you provided. Is this still the correct address (read off the address they wrote on sign-in sheet and update if necessary)? Again, thank you for your time. Have a great day!

Last updated June 1, 2017

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