AB617 Community Input form

AB617 Community Self-Recommendation Form

Note: Information provided by you on this worksheet (including contact or other personal information) is a public record and may be released in response to a California Public Records Act request

Date

Contact Information

1. First and Last Name

2. Phone

3. Email

4. Organization (if applicable)

Input on Community Selection and Priorities

5. Was this community area recommended in the previous year?

6. Is there any new information available from 2018-2019 that could be considered in prioritizing communities for this program? (yes or no)

If yes, please elaborate.

7. Is there any new information available from 2020-2021 that could be considered in prioritizing communities for this program? If yes, please elaborate.

Community information

8. Community name (as known by community members)

9. What areas does this community include? (City Name, Neighborhood Name, and Zip Code):

10. Is your community recommending itself for deployment of a community air monitoring campaign, for development of a community emissions reduction program, or both?

Community air monitoring
Community emissions reduction program
Both

11. Why and for what purpose? (Related to question 9)

12. What are the characteristics of your community that make it a good candidate for this program? For example, this could include having many engaged community organizations, experience with developing and implementing community plans, and demonstrated experience and willingness to collaborate with diverse stakeholders (government agencies, community organizations, businesses, schools, hospitals, etc.).

Additional information

13. Would you like to sign up for updates on AB 617? Select yes to be included in the email list

Yes
No

File Upload (optional)

Submit a letter or additional documents