Register Your Community

Tell us who you are

First name: *

Last name: *

Title/Position:

Organization:

Street Address:

City: *

State: *

Use two-letter, U.S. postal code abbreviation if applicable.

Zip Code: *

Phone Number: *

Email Address: *

The Local Environment

Are you aware of currently or previously existing problems with surface water quality that may be the cause of health problems: *

Yes

Unsure

(rivers, streams, lakes)

Are you aware of any currently or previously existing problems with drinking water that may be the cause of health problems: *

Yes

Unsure

In your own words, briefly describe how you view the environmental health problem in your community: *

The connection between the environmental contamination in your community and health problems

How sure are you that the number of illnesses found in your community is unusual: *

Not sure

Somewhat sure

Very sure

Certain

What other things may be causing the health problems (ex. smoking, lifestyle, poverty, exposure to contamination at work): *

These are things in addition to environmental contamination.

How much is known about the relationship between contamination and the incidence of illness: *

Unknown at this time

Suspected connection (word of mouth, initial investigation)

Very likely connection (more in depth investigation)

Established connection (scientific research)

Help and Action

Is there an active group with people willing to work on this issue (choose one of the following): *

An active community group has been working on the issue

An active community group that addresses broader issues is interested in taking this issue

An active community group that addresses broader issues might be interested in this issue

If there is a group already or potentially working on this issue, how many active/involved volunteers does the group have: *

If there is a group already or potentially working on this issue, how many full time equivalent paid staff does the group have: *

Are there professionals in the community that would likely volunteer technical assistance to help investigate the problem: *

Most likely outside their official capacity. Check all that apply.

Collectively, what type of help was received:

	Telephone help	Internet help	Brief in-person help	Intensive in-person help
Help understanding the issue
Help conducting a health survey
Identification of potential areas of contamination/risk
Help monitoring your water
Help researching discharges in your community
Help understanding discharge permits
Community organizing (e.g., involving people, planning political campaigns)
Building your organization (e.g., Fundraising, Board development)
Legal Assistance
Other

If "other," please describe:

Please rate how needed each of the following types of help are:

	not needed	somewhat needed	very needed
Guidance for resources available on the web
Health Surveys: Help with sampling and methodology (In a scientific survey, there is a lot to know about exactly which people should be surveyed and how)
Health Surveys: How to develop one (In a scientific survey, it's very important what questions are asked and in what order)
Health Surveys: How to analyze results
Identification of potential areas of contamination/risk
Monitoring for toxics: How to sample and analyze ourselves
Monitoring for toxics: How to sample and a list of labs that can do the analysis
Monitoring for toxics: Help paying for
Help researching toxics discharged in our community
Help understanding discharge permits
Help understanding laws like Clean Water Act, Safe Drinking Water Act, Superfund, RCRA, etc.
Community organizing (e.g., involving pore people, planning political campaigns)
Building your organization (e.g., fundraising, Board development, leadership training)
Legal Assistance
Other (only if "very needed)

If "other," please specify:

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