Form 6700-032 HIA Training Feedback Storytelling Activity

OMB Control Number: 2030-0051

Expiration Date: 05/31/2024

“This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2030-0051). Responses to this collection of information are voluntary 5 CFR 1320. 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 range between 5 to 20 minutes for this activity. 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.”

Health Impact Assessment Feedback Activity (Storytelling Activity Option*):

*The project’s Environmental Justice Community Advisory Board will decide on survey delivery mode (traditional focus group and/or storytelling survey) and make modifications to these questions based on project needs.

Facilitator Script: “Thank-you for participating in our Health Impact Assessment Training Sessions. We would like to gain further feedback regarding potential Environmental Justice Programs Cuyahoga County Board of Health is considering in your area including the Health Urban Tree Canopy Program and Healthful Homes. Remember responses are voluntary.

Before we get started can each of you briefly fill out the notecard for the community you are representing, how long you have lived or worked in this community, your age range, and if you would like to be considered for participation in program activities.”

On your tables you will see an activity (Figure) to gain feedback about what environmental burdens you are most impacted by. This open-ended activity is meant to be fun and creative so you can tell your stories and help us co-plan potential programs. On your tables, you will see one piece of paper with a bullseye and a set of stickers. At the top of the bullseye sheet you will see the question “What environmental burdens are impacting you and your family the most?” Feel free to use the stickers however you would like putting the most important things in the center and lesser important things in the outer rings or in the dashed box. You may use as many or as little stickers as you want. If something isn’t on there that you think is important, please use the blank stickers to write it in. After you are done we will go around the table for each of you to tell your stories! Feel free to ask us if you have any questions. Remember when telling your stories do not use any identifying information.

Figure. OSU’s Public Engagement to Re-imagine Community Co-Planning (PERCC) Bullseye Activity. Representative Example of Storytelling Activity developed by Dr. Michael Rayo, Associate Professor, Integrated Systems Engineering & Health.

Notecard (Regardless of Feedback Activity Option Selected):

Community you are representing (Please circle one):

East Cleveland / Euclid / Maple Heights

Years lived or worked in community (Please circle one):

Less than 1 year / 1 – 5 years / 6 – 10 years / Over 10 years

What is your age range? (Please circle one):

Less than 18 years old / 18 – 65 years old / Greater than 65 years old

Would you like to be considered for participation in program activities? (Please circle one):

Yes / No

• If yes, please print your preferred method of communication:

  • Email: __________________________________________________________________

  • Mail: __________________________________________________________________

  • Phone Number: __________________________________________________________________

EPA Form: 6700-032