OMB Control Number: 2030-0051
Expiration Date: 05/31/2024
EJ TCTAC Intake Form Center A
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2030-0051. Responses to this collection of information are voluntary. 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. The public reporting and recordkeeping burden for this collection of information is estimated to 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 to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
Required: The collection of information required for the rendering of appropriate services deployed by Center A.
Your information
Your first name
Your last name
Your title
Your organization/business name or community affiliation (write N/A
if not applicable) [Response is Required]
Website of your organization/business (if applicable)
Which of the following best describes your business/organization?(Select
all that apply) [Response is Required]
Community based or grassroots organization
Nonprofit organization
Philanthropic
Tribal Government or Intertribal Consortia
Native American Organization (includes nonprofits, cooperatives, corporations, partnerships)
Local Governments (as defined by 2 CFR 200.1 – includes cities, towns, municipalities,
and counties, public housing authorities and councils of government)
Institutions of higher education (e.g., private and public universities and colleges,
including community colleges)
Private business
Special district
Don't know/Not sure
Other (please specify)
Preferred form of contact
[Response is Required]
Phone call
SMS/text messaging
If previous response = Email
Please provide your E-mail address for future communications
[Open ended]
What is your preferred language for future communications?
[Open ended]
If previous response = phone call or SMS
Please provide your phone number for future communications
[Open ended]
What is your preferred language for future communications?
[Open ended]
Community information
Please provide the following socio-demographic information for the impacted community or communities for which you are seeking technical assistance.
Name of the community [Open ended]
Which state is this community located in? (Select all that apply) [Response is Required]
Alaska
Idaho
Oregon
Washington
Other (please specify)
Please select the group(s) that represent the impacted community or communities. (Select all that apply) [Response is Required]
Asian
Black or African American
Elder persons (i.e., 65 years and older)
Hispanic or Latino/Latina/Latinx
Houseless persons
Immigrants
Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons
Low income persons
Middle Eastern or North African
Mesoamerican Indigenous
Native Hawaiian and Pacific Islanders
Native American/Indigenous/American Indian/Alaska Native
Persons who live in rural or remote areas
Persons with disabilities
Refugees
Religious minorities
Other, please specify
(The information will be gathered to understand the reach of the program to priority communities. )
Please use this space if you would like to provide more details about
the group(s) that represent the impacted community or communities. (e.g., Thai community in Eastern Oregon).[Open
ended]
What is the approximate population of the impacted community?
[Response is Required]
2,500 or under
2,500 to 10,000
10,000 to 50,000
More than 50,000
I am not sure
What is the preferred communication language of the impacted community?
[Open ended]
Environmental or Energy Justice Issue
Please provide a brief description (500 words or less) of the energy or environmental
justice issue faced by the impacted community or communities. [Open
ended] [Response is Required]
How can we help you? In 500 words or less, please describe the assistance you’re looking
for. If you’re not sure, that’s ok, we will follow up with you to discuss further.
[Open ended] [Response is Required]
In 500 words or less, please share what is the desired community outcome for this request?
If you’re not sure, that’s ok, we will follow up with you to discuss further.
[Open ended] [Response is Required]
Final section
How
did you hear about the Northwest Environmental Justice Center? [Open
ended] [Response is Required]
EPA Form: 5800-091
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Godwin, Audrey |
File Created | 2024:11:10 09:25:22Z |