Form 6700-034 Healthy Homes and ECO Neighborhoods Survey

OMB Control Number: 2030-0051

Expiration Date: 05/31/2024

Healthy Homes and ECO Neighborhoods Survey

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. 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 from 5 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.

Please take a few minutes to complete a survey of today’s learning experience. By completing the survey, you are agreeing that your anonymized responses may be used in reporting and communicating with partners. This survey is being carried out as part of a program facilitated by [Clean Wisconsin or Sherman Park Community Association] and in partnership with the EPA and City of Milwaukee. Your response is appreciated!

For the following questions, please circle the number that most accurately reflects your experience.

1. Today’s learning experience increased your understanding of the topic:

Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1	2	3	4	5

2. After today’s learning experience, I know who to contact for more information or resources on the topic:

Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1	2	3	4	5

3. How likely are you to use this information and resources in your daily life?

Not at All	Slightly	Moderately	Very	Extremely
1	2	3	4	5

4. If you see yourself using this information and resources in your daily life, please share how you will use it.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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5. What would prevent you from using this information and resources in your daily life?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Please share any additional information and/or resources you would like or questions you may have.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Demographics

Please provide the following demographic information about yourself. This information is used to ensure our programming reaches diverse audiences. If you choose not to provide this information, please choose the ‘Prefer not to respond’ option for each item.

Zip Code

Write In: _________________

Race and/or Ethnicity

• American Indian or Alaskan Native

• Asian

• Black or African American

• Middle Eastern or North African

• Native Hawaiian or Other Pacific Islander

• Two or More Races

• White

• Hispanic or Latino/Latinx

• Prefer not to respond

Age

• Adult (19 years or older)

• Youth (18 years or younger)

• Prefer not to respond

Gender

• Female

• Male

• Nonbinary or Another identity not listed _____________________________________

• Prefer not to respond

Household Income

• Less than $20,000

• $20,000 to $34,999

• $35,000 to $49,999

• $50,000 to $74,999

• $75,000 to $99,999

• Over $100,000

• Prefer not to respond

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Highest Level of Education

• Preschool through 8^th grade

• Some High School

• High School or GED

• Some college credits

• Associate’s Degree

• Bachelor’s Degree

• Master’s Degree

• Ph. D or higher

• Trade School

• Prefer not to respond

Thank you!

EPA Form: 6700-034