PHA Guidance Manual

• Table of Contents
• Foreword
• Disclaimer
• Chapter 1: Introduction
• Chapter 2: Public Health Assessment Overview
• Chapter 3: Obtaining Site Information
• Chapter 4: Involving and Communicating With the Community
• Chapter 5: Exposure Evaluation: Evaluating Environmental Contamination
• Chapter 6: Exposure Evaluation: Evaluating Exposure Pathways
• Chapter 7: Health Effects Evaluation: Screening Analysis
• Chapter 8: Health Effects Evaluation: In-depth Analysis
• Chapter 9: Determining Conclusions and Recommendations
• Appendices
• Tables
• Figures

Chapter 4: Involving and Communicating With the Community

• (Section 4.1) introduces terms used in this chapter, describes community involvement objectives, and presents the roles of various program offices and site team members.
  
  
• (Section 4.2) provides information about interacting and effectively communicating with community members throughout the public health assessment process.
  
  
• (Section 4.3) provides an overview of the steps involved in planning community involvement activities at your site.
  
  
• (Sections 4.4) and (4.5) show how community involvement is included in the public health assessment process, including tools that can be used in the process.
  
  
• (Section 4.6) explains how to respond to community health concerns in the public health assessment document.
  
  
• (Section 4.7) discusses the public comment process and the release of final documents.
  
  
• (Section 4.8) provides some general procedural information about disseminating information to the community.

The community associated with a site is both an important resource for and a key audience in the public health assessment process. Community members can often provide information that will contribute to the quality of your scientific assessment. In turn, they will want to know

• What the public health assessment process involves.
  
  
• What conclusions you reach.
  
  
• How ATSDR and the public health assessment process can help address their health concerns.
  
  
• How they can become involved in the process.

ATSDR has embraced the philosophy of continuous improvement of and increased attention to its community involvement efforts. The practice of community involvement requires earnest, respectful, and continued attention. One of the keys to the success of the public health assessment process lies in the ability to establish clear expectations, communicate effectively, and place the community at the center of its response.

The relationship the team builds with the community will influence how much community members trust you and thus, ultimately, how they react to your public health messages and recommendations. For all these reasons, effective community involvement is an important part of the public health assessment process.

The purpose of this chapter is to provide information on how to involve the community in the public health assessment process. As a health assessor, it is important for you to have a good understanding of the purpose, approaches and tools for involving the community, and to work effectively with your team to promote community participation during the public health assessment process. This will help your site team initiate and maintain good two-way communication between ATSDR and the community.

This chapter is not intended to provide all information about conducting community involvement, health communication, or health promotion activities. Rather, it describes the tools and resources for an effective site-specific approach. If additional information is needed, contact the health communication involvement or health education specialist on your team. ATSDR partners may find that some discussions in this chapter are not necessarily relevant to their particular procedures (e.g., use of ATSDR's Community Involvement Branch), but the process of effective community involvement is the same.

Note that community involvement strategies and activities are site-specific—dependent on the community, the site, the possible public health hazard, available resources, and other issues. Not all community involvement activities occur at all sites. Strategies can change over time based on input from the community and other stakeholders throughout the public health assessment process. For each site, the team will need to make judgments about which community involvement activities are appropriate based on the site situation, and possibly based on resource availability.

Figure 4-1 shows the general components of the community involvement process. This chapter provides guidance for the health assessor in each of these areas.

4.1 Definitions, Goals and Objectives, and Program Roles

To effectively communicate with the public and foster opportunities for their involvement in the public health assessment process, it is important to understand (1) the basic terminology describing the process, (2) the overall goals and objectives of community involvement, and (3) the roles of the various agency programs in the community involvement process.

4.1.1 Definitions

Terms used throughout this chapter are defined as follows:

4.1.2 Goals and Objectives for Community Involvement

Community involvement activities should be developed and implemented with the following objectives in mind.

• Earning trust and credibility through open, compassionate, and respectful communications.
  
  
• Helping community members understand what the public health assessment process involves.
  
  
• Providing opportunities for communities to become involved in ATSDR's public health assessment activities.
  
  
• Promoting collaboration between ATSDR, communities, and other agencies.
  
  
• Informing and updating communities about ATSDR's work through managing and coordinating health communication activities with site communities.
  
  
• Helping communities understand the possible health impact of exposures to hazardous substances (or the lack thereof).

4.1.3 Program Areas Addressing Community Needs

As described in Chapter 2, the team leader is responsible for organizing a site team with the combined expertise necessary to address most or all of the needs of the community. Depending on site-specific needs, team members from various programs will participate in community involvement efforts at different levels. For some team members, such as those from ATSDR's Community Involvement Branch (CIB), community involvement is their main responsibility. Others may take more of a managerial, complementary, or supportive role. Table 4-1 outlines program areas and associated responsibilities for working with communities. Included in the table are a list of ATSDR programs/specialists, their general roles, and when you might consider including them on your team. ATSDR partners involved in the public health assessment process will call upon their local team resources to plan and implement community involvement and associated activities.

Table 4-1. ATSDR Program Areas with Responsibilities for Working with Communities

Program	Specialists	Role in the Public Health Assessment Process	Role in Community Involvement	When Included on Site Team?
Division of Health Assessment and Consultation (DHAC) (http://www.atsdr. cdc.gov/HAC/)	Health assessors, toxicologists, medical officers, other science specialties, health communication specialists.	The site team leader is almost always a health assessor who brings together a team of ATSDR staff to address the needs of the site; coordinates the site team; collaborates with other groups and agencies; evaluates environmental health data; and who is responsible for preparing public health assessment documents. Other science specialists from DHAC are often needed to address specific site issues.	The site team determines the community involvement activities that will be conducted. The team leader is usually involved in implementing community involvement activities; other DHAC scientists may be also become involved.	A DHAC health assessor is usually the team lead for all public health assessment activities and must be included on the site team. Other science specialists from DHAC are often needed to address specific site issues.
Division of Regional Operations (DRO) (http://www.atsdr.cdc.gov/DRO/)	Regional representative	Acts as a liaison with EPA; facilitates implementation of ATSDR's work in the regions; maintains current and historic knowledge of the sites and issues in the specific regions; provides and follows up on ATSDR recommendations; sometimes reviews site-specific information.	Because of proximity to communities, is often the first ATSDR staff to contact communities. Works with site team to develop and implement community involvement activities. Attends almost all ATSDR community meetings; may also attend those of other agencies. Often takes lead on political issues.	The regional representative is always included on the site team and kept informed of public health assessment activities.
Community Involvement Branch (CIB)	Health communication specialists	Provides a central point of contact for community members at most sites.	Takes lead on site team in developing and implementing community involvement activities; manages and coordinates community involvement activities with site team, the community, other groups and agencies; conducts community meetings; works with media; and develops culturally-specific materials, such as fact sheets.	1) Whenever site team lead and the regional representative need additional support for community issues. 2) For petition sites not assigned to cooperative agreement partners. Note: CIB must prepare press releases for all documents released.
Office of Tribal Affairs (OTA) (http://www.atsdr.cdc.gov/tribal/)	Environmental health scientists	Provides a central, identifiable point of contact for American Indian and Alaska Native communities.	Provides tribal-cultural assistance on site-specific projects; develops needed interagency coordination to address environmental health needs of American Indian and Alaska Native populations.	OTA must be kept informed and/or included on any site team working with American Indian and Alaska Native communities.
Division of Health Education and Promotion (http://www.atsdr.cdc.gov/ dhep.html)	Health education, communication, and professional educator specialists	Works with communities to understand, prevent, and/or mitigate adverse health effects associated with hazardous substances present in their communities.	Assesses health education needs including access to care; mobilizes community and institutional partnerships; builds state and local capacity; addresses health education and other community needs.	During the public health assessment process or after the evaluation is completed.
Office of Communication (http://www.atsdr.cdc.gov/ orgchart.html)	Public affairs specialists, writer/editors, and visual information specialists	Provides direction and essential support to the agency in the areas of policy, state capacity coordination, marketing, publications and public affairs, visual information services, and congressional inquiries.	Assists with 1) public notices and press releases; 2) visual information services; 3) public affairs as it pertains to community involvement; and 4) translating technical health risk information for the lay public.	As needed.
NCEH/ATSDR Office of the Director– Environmental Justice (http://www.atsdr.cdc.gov/ orgchart.html)		Provides leadership in the areas of minority health and environmental justice.	Coordinates activities and programs for minority communities, under-served communities, and low-income communities.	As needed.
Ombudsman (http://www.atsdr.cdc.gov/ COM/omweb.html)		An independent, neutral resource service for all parties (including communities) concerned with environmental health disputes involving ATSDR.	The ATSDR ombudsman can be called to impartially investigate, mediate, and assist, when all routine avenues have been exhausted. The ombudsman is an advocate for problem resolution.	As needed.
Washington, D.C. Office (http://www.atsdr.cdc.gov/ legislation/)		Provides a critical information link in Washington between ATSDR and the legislative branch and the other executive branch agencies of government; improves the environmental health policy-making process by sharing ATSDR's science-based recommendations and conclusions with Congress.	Provides information to congressional members and their staffs about 1) ATSDR's site work within their legislative jurisdictions, 2) identifying environmental health resources for communities exposed to hazardous substances.	As needed.
Office of the Director (http://www.atsdr.cdc.gov/ orgchart.html)		Promotes programs in support of environmental health issues; supports applied research activities relevant to ATSDR's mission through the development and implementation of research plans and science policy for the agency.	Provides oversight and review for some sites.	As needed.

4.2 Working and Communicating with Community Members

A critical element to the success of any community involvement, health communication, or health education and promotion activity, is effective communication with all members of the site community. To effectively communicate your message(s) you will need to 1) earn the trust of and prove your credibility to the community; 2) assure them you are sensitive to issues of confidentiality and privacy, 3) be conscious of cultural sensitivity when interacting with community members, 4) be aware of possible environmental justice concerns that may be present at your site. This section provides you with tips and information about ATSDR's approaches to all of the above. The last subsection also includes some principles for effective communication. (Additional suggestions for effective communication and considerations when interacting with the site community may be found in Appendix D). Again, the community involvement specialist on your team can help you develop a plan and approach with any community involvement activities, but it is important for the health assessor to know what to keep in mind in his or her interactions with community members.

Appendix C provides a "community check list" developed by the Community/Tribal Subcommittee of ATSDR's Board of Scientific Counselors. This check list can be used by community members and health assessors as a guide in helping to ensure that the public health assessment process at a particular site is responsive to community health concerns and information needs.

4.2.1 Earning Trust and Credibility

ATSDR's relationship with the community is influenced by every interaction with community members. The more opportunities ATSDR creates to get to know the community better, to listen respectfully to their concerns, and to help them understand how the agency's activities will respond to their concerns, the more the community will trust ATSDR's work at the site. Trust lays the foundation for community cooperation during the public health assessment process and for the community's willingness to accept your results and conclusions and respond to your recommendations. For all these reasons, building trust is central to working with community members.

4.2.2 Confidentiality and Privacy

Personal information that ATSDR receives from the public, such as petition letters, community health concerns, and medical records may be considered confidential and may contain sensitive personal information. As discussed in Chapter 3 (Section 3.5), such data must be handled in accordance with agency guidance specific to confidentiality and privacy issues (e.g., when interacting with the public at meetings or when presenting information in written products). Potentially confidential or sensitive data include:

• Biologic/medical data
  
  
• Environmental data from private properties
  
  
• Some GIS information/data/maps
  
  
• Summaries of health information provided by community members, including names and addresses of community members

Different state and tribal policies related to confidentiality and privacy may also exist.

4.2.3 Cultural Sensitivity

In many communities, concerned or potentially impacted groups may include different ethnic or minority groups and/or members of tribal nations. To be successful, you will need to conduct your communication and involvement activities in a way that is sensitive to each group's culture and language. For example, two or more variations of outreach materials may be needed when a community contains cultural groups with significantly different profiles, concerns, behaviors, or languages.

During the initial reconnaissance of a site, the site team should identify any distinct groups within the local community (e.g., ethnic, tribal) and during telephone or subsequent in-person interviews arrange for interpreters as necessary. This initial information will help you determine whether you will need cultural contacts and interpreters during the public health assessment process. A cultural contact acts as a bridge between the cultural community and the site team and provides guidance to the site team on the most culturally appropriate, constructive, and productive ways for learning from, informing, and involving the community. The best cultural contact is someone from the community who is fluent in both English and the language of the cultural community, familiar with the community's cultural habits, and trusted by community members.

During the early stages of the public health assessment, you can work with local organizations and community leaders to identify the most appropriate cultural contacts. When tribal members are part of the site community, you will consult with ATSDR's Office of Tribal Affairs who can help you identify site-specific tribal issues and concerns. Other government agencies, such as the Indian Health Service, may also be able to provide guidance on cultural contacts. The cultural contact may or may not also act as an interpreter, depending on his or her skills and experience. As needed, your health communication specialist can help you identify skilled and reliable interpreters and translators who can provide unbiased oral and written translation between English and the community language.

4.2.4 Environmental Justice

Environmental justice refers to efforts to ensure that all populations, regardless of their economic status or political power, are treated equally with respect to the development, implementation and enforcement of environmental laws, regulations, and policies. These efforts help ensure that no population unfairly shoulders the negative human health and environmental impacts of pollution. NCEH/ATSDR's Office of the Director, Environmental Justice (EJ), has leadership responsibility for addressing environmental justice issues related to ATSDR's work in communities. The EJ program works in collaboration with other ATSDR divisions and offices to identify and address real or perceived environmental injustices in communities of concern. Environmental justice activities are initiated when there is a perceived or real concern by a minority and/or low income community that they have not been appropriately involved in matters concerning planning, implementing or evaluating activities related to the environment or environmental health. It is important to be aware of the EJ program's role and alert for signs of any environmental justice concerns within the community at your site. If any such concerns are raised by community members at any time during the health assessment process, you should contact the EJ program to determine the next steps with regard to these concerns.

4.2.5 Principles of Effective Communication

As a health assessor, you will face two key challenges in communicating with the public during the public health assessment process:

• First, public health assessment information often is technical in nature, yet most community members are not technical specialists. Health assessors must therefore strive to present information in as clear and understandable a manner as possible without sacrificing accuracy. Clear communication is particularly important in three places in your public health assessment document: the Summary, Conclusions, and Recommendations. These sections are widely read by not only the community but other key stakeholders.
  
  
• Second, a number of community members often will, understandably, have strong feelings and opinions about the site. Thus communication entails not only the exchange of information, but just as importantly, listening to, understanding, respecting, and responding with compassion to the feelings and concerns of community members.

Through experience and research, public health professionals and other experts have developed basic principles and practices for communicating clearly and compassionately. Guidance on implementing these principles is provided in Appendix D. Following these guidelines from the beginning to the end of the public health assessment process will help build trust with the community—the critical foundation for a successful and credible public health assessment process. Affected community members and involved community groups should be included when possible. Remember that all community contact—particularly your initial contact—sets the tone for your continued work with the community.

As you develop communication materials, you should work with the health communication specialist on your team to ensure that your communications—particularly written materials—follow these principles. Also, where possible and appropriate, utilize technical writers, communication specialists, and the community to help ensure the quality and success of your communications. You can also refer to ATSDR's A Primer on Health Risk Communication Principles and Practices (http://www.atsdr.cdc.gov/HEC/primer.html) which provides additional information on communication guidelines, comparing risks, and responding to questions from community members.

Additional resources related to effective communication are provided at the end of this chapter.

4.3 Planning Community Involvement Activities

The extent of public communication and involvement at a particular site depends on several factors including:

• How concerned the community is about the site.
  
  
• The potential for public health hazards from the site, as determined by your data and the evaluation as it proceeds.
  
  
• The availability of resources to implement the communication and involvement activities.

This section outlines the steps involved in developing community involvement strategies and the types of activities that may be appropriate depending on your site-specific issues.

4.3.1 Overview of Community Involvement in the Public Health Assessment Process

Public communication and involvement during the public health assessment process can be divided into four stages:

• Getting started. Through your initial public health assessment activities, you will start to build a relationship with the community. You will also gather information about the site, the community, and its needs and concerns. This information will provide a foundation from which you can plan your subsequent community involvement activities. In some cases, concerns brought to ATSDR's attention may need to be referred to another agency, such as worker-related concerns. Whenever possible ATSDR should notify community members early in the public health assessment process if their concerns are beyond the scope of ATSDR's mission. It is equally important that community members be informed and understand early in the process what ATSDR can do and what the public health assessment process represents.
  
  
• Ongoing activities as the public health assessment is conducted. The type and nature of communication, education, and involvement activities during this stage will depend on the needs and interests expressed by the community during the previous stage, the public health issues identified at the site by the site team throughout the public health assessment process, and the resources available for communication, education, and involvement activities. While the public health assessment is underway, primary communication and involvement goals include updating the community on the status of the assessment, obtaining ongoing feedback on the process, obtaining additional information as needed or available from the community for the assessment, and recommending public health actions, if needed, about how community members can protect their health (e.g., encouraging lead testing in children, limiting backyard gardening activities).
  
  
• Public comment on the draft public health assessment document (PHA). For public health assessments, the next stage begins after you prepare the draft PHA. During this stage you will be following a formal process to ensure the public has a chance to comment on the draft document. (Note: public comment is not required but may be desirable for some public health consultations.)
  
  
• Communication of final results and follow-up activities. Once your public health assessment document is finalized, you will need to release the document to the public and communicate the key results, limitations, and recommendations. If ATSDR or other parties will be conducting any follow-up activities at the site (such as additional environmental sampling, exposure investigations, health education, or health studies), you may need to plan community involvement activities as appropriate in conjunction with these activities.

4.3.2 Developing Community Involvement Strategies

Team members will develop strategies for involving and interacting with the public throughout the public health assessment process. The health communication specialist on your team will define which tools are most appropriate for the particular circumstances at your site and when they should be used. In addition to site-specific issues, the team must also consider whether ATSDR has sufficient resources to implement the strategies. Other agencies and groups (e.g., federal, and state health and environmental agencies, tribal governments, local health departments, citizens' advisory groups, and medical advisory groups) may already be working with and providing information to community members at a site. As appropriate, the team should collaborate with these groups to enhance the efficiency, effectiveness, and credibility of public communication and involvement activities. Also, the team may need to change strategies as the public health assessment process progresses.

Community involvement strategies will be based on factors such as:

• The community's level of concern, interest in the site, and other community issues
  
  
• Environmental public health factors
  
  
• Political and congressional issues
  
  
• Other site-specific considerations, such as how many people are on the site team and how many other agencies are collaborating with ATSDR on the site

Table 4-2 lists some of the issues that the team should consider when developing community involvement strategies. Focus on community concerns related to public health issues.

Table 4-2. Issues to be Considered When Developing Community Involvement Strategies

Type	Issues to be Considered When Developing Community Involvement Strategies
Community	Community's Health Concerns: How many community members are concerned about site? What is the level of the community's concern? Is the level of community concern higher (or lower) than would be expected based on the environmental health risk alone at the site? Are community concerns known? Demographics: How many community members live near site? Are there any potentially sensitive populations that could be exposed? Does socio-demographic information suggest a need for additional community involvement resources, such as translation, interpreter services, or cultural brokers? How do the community members get information? From newspaper, radio, television, Internet, word-of-mouth? Community's interest in the public health assessment process: How involved in the public health assessment process would the community like to be? How would the community like to be kept updated and informed about ATSDR's activities and work? Community meetings? Fact sheets? Specific types of media? Would some community members or community groups prefer e-mailed newsletters and updates? How many community and/or activist groups are involved? How active are they? Will ATSDR be working with a specific community group already formed or should the agency consider forming a new one? Media Support: What has the community already heard from the media? Are there misconceptions that need to be dispelled? Will media support require more community involvement resources than usual? Should the Office of Communication be directly involved? ATSDR's support of the community: Are there American Indian or Alaskan Native communities at the site? Should the Office of Tribal Affairs (OTA) be involved at the site? Are there particular issues of concern (e.g., environmental justice, child health, Brownsfield) at the site? Will the Environmental Justice program be involved? What past experiences has the community had with government agencies? Does the site have a higher level of need for community involvement resources, such as the need to keep the community informed more regularly than usual? How active will the regional representative be in community involvement efforts? The Division of Health Education and Promotion (DHEP)?
Environmental Public Health	Is the site a public health hazard? Is the hazard acute or chronic? Are environmental health risks unknown? Does DHAC/ATSDR management consider the site a high priority? Does site work involve a health study or exposure investigation? Are there any health outcome data or biologic data relevant to the site? Does it seem plausible that a health connection could be established between contaminant exposures and community health concerns? Would a physician enhance outreach at the community meetings? Are data available for review now or must DHAC wait for it? If site is a Superfund site, where is it in the remedial process? Has ATSDR only recently become involved in this site? Or has ATSDR almost completed its work at this site? Do the community members need information/outreach/health education now or can this wait until a report (e.g., PHA, PHC) is generated?
Political/Congressional	Is the ATSDR Washington Office already involved? Informed? What other agencies are involved and must be kept updated? Is coordination with other agencies especially difficult? How often will congressional briefings be required? How many agencies, congressional staffers, and other political entities, will need to be notified in a certain order, with a certain protocol? How resource-intensive will this be? Will the regional representative be taking the lead on political issues?
Other	How many people are on the site team? How many divisions/offices are involved? What is the time frame for report (e.g., PHA, PHC, fact sheet) development and communication? What type of clearance will be required? At what levels? Will the Visual Information Center (VIC) be involved in preparing outreach materials?

4.3.3 Types of Community Involvement Activities

Various options for involving the community are available. Determining the activities most appropriate for a site typically involves discussions among the site team as well as with the community. Community involvement activities can occur throughout the public health assessment process, from information gathering stages through implementation of recommendations or public health actions, such as during a health study or an exposure investigation.

Opportunities for site communities to become involved in the public health assessment may include the following. The specific tools for implementing these activities are discussed in the remainder of this chapter.

• Individual one-on-one sessions to enable community members to inform the site team about their health concerns and other information.
  
  
• Meetings, conference calls, and informational mailings to keep the community updated about the status of public health assessment activities.
  
  
• Formal or informal community groups to discuss issues and formulate questions.
  
  
• Public comment periods to enable community input on draft public health assessment documents (e.g., PHAs).
  
  
• Access to experts at ATSDR that enable community members and other stakeholders to:
  
  
  • Obtain site-related public health information and any explanations that may be needed.
    
    
  • Add names to the site mailing list.
    
    
  • Provide health concerns or other information about the site.
    
    
  • Express their desire to influence site activities.
    
    
  • Provide feedback about ATSDR's public health assessment activities at a site.

4.4 Community Involvement Tools

The following information will familiarize you with frequently used community involvement tools or activities. Not all of these tools will be used at every site. Section 4.4 outlines how the level of community involvement activities may vary from site to site depending on the phase of the public health assessment process, the level of community interest, and the degree of hazard a site poses.

4.4.1 Tools for Initial Data Gathering

A first step in the public health assessment process is gathering information about the site and the characteristics of the site community. The team will initially review information readily available about the site. This may include information documenting site conditions (e.g., site investigation reports) or community health concerns (e.g., a petition letter). As you collect information, the site team can begin to determine how much community interest and concern there is about the site, identify some of the community leaders, and decide what shorter- and longer-term activities might be warranted. See also Chapter 2, which highlights the important first steps in the public health assessment process, and Chapter 3, which provides detailed guidance on collecting site information, including information specific to the site community.

Geographical information system (GIS) and various Internet tools can be helpful early in the process to obtain information about the general characteristics of the site community, especially before the site team visits the community. For example, introductory GIS maps generated based on U.S. Census data can assist in identifying populations near the site and populations that might be more susceptible to site contamination. In some cases, social characterization maps can be generated to help anticipate various characteristics of the population and to prompt the team to ask appropriate questions during the site visit. During the site visit and subsequent communications with the community, you will learn first-hand more about specific characteristics of the community and how they may influence community involvement activities (see Table 4-2). The Internet is also a good source of demographic and other types of information. Claritas, Inc., for example, has a Web site that summarizes lifestyle groups for 5-digit zip code areas (www.claritas.com). See Chapter 3 for additional Internet resources.

4.4.2 Community Meetings

Community meetings can be held throughout the public health assessment process and in several formats depending on the type of interaction that the community has requested and what is needed to address the community's site-specific health issues.

Different meeting formats will be suitable depending on the purpose of the meeting and the information needs and preferences of the site community. These include:

• Interviews. One-on-one meetings with local community members who represent different groups and perspectives within the local community. Interviews can be conducted in person or by telephone. For petitioned public health assessments, interviews with the petitioners are the highest priority.
  
  
• Public availability session. An informal meeting where community members can talk confidentially one-on-one with ATSDR about their health- and site-related concerns. ATSDR uses the community health concerns gathered at this session to help direct the public health assessment process.
  
  
• Poster sessions. Gatherings where ATSDR meets with community members in small groups to discuss information displayed on posters on a wall or table top. A poster session could have a theme, for example, ATSDR and the public health assessment process. Agency staff are available at these sessions to give informal presentations, answer questions, and discuss concerns with interested members of the public. Representatives from other agencies may also display information and discuss their agencies' work at the site. Attendees have the opportunity to ask questions and share their concerns in smaller group settings than would be possible in public meetings.
  
  
• Public meetings. ATSDR and (possibly) representatives from other agencies meet with community members to discuss the public health assessment process and the findings of its site-specific evaluations. A specific agenda is developed prior to the meeting by the site team, with community member input, when possible. Agency representatives and experts discuss the public health activities and community involvement conducted at the site—past, current, and planned future activities. ATSDR often includes a question and answer period during the meeting.
  
  
• Public availability meeting and poster session combination. Community members can learn about ongoing public health assessment activities at the poster session as they wait to discuss their health concerns individually with an ATSDR representative.
  
  
• Public meetings and poster session combination. An initial public meeting is held to provide general information to the community and to respond to their questions; afterwards the larger group divides to learn more about specific aspects of the site through a poster session.
  
  
• Other meetings. Other types of meetings can be held in response to specific community needs or environmental issues. These may include meetings of community groups, local officials, workgroups formed to address a particular issue, or workshops conducted to provide technical or educational information to communities.

4.4.3 Community Groups and Committees

ATSDR has had the opportunity to work with various types of informal community or neighborhood groups. These groups are made up of people who have decided to work together to address one or more issues related to environmental contamination in their neighborhood and its possible effect on the health of the community. Sometimes neighborhood groups grow in numbers and in impact such that their membership expands to include not only current residents, but also former residents; local environmental activists; national environmental activists; local and national officials; local, state, tribal, and federal agency representatives; and others. As the group becomes more formalized with specific procedures and policies, it may be described as a coalition, alliance, or forum.

Community members at some sites prefer more direct participation in the public health assessment process. ATSDR works with community groups to determine the best way for the agency to meet their needs and, at the same time, obtain the information needed for the public health assessment process. ATSDR's role can range from being a participant to having some responsibilities for conducting group meetings.

At a specific site, there might be several different community groups, each with a specific mission and goals. ATSDR staff strive to ensure that the agency interacts with all segments of a community, not just organized community groups, but also individuals who may even be unaware of the environmental concerns. When segments of a community are strongly divided over the public health issues and activities at a site, ATSDR may recommend establishing a formal community participation group.

4.4.3.1 Community Groups Established by ATSDR

Community members can become involved in planning, implementing, and decision-making through a community group established by ATSDR. With this mechanism, ATSDR can engage interested community members in data collection and evaluation, joint problem-solving, the preparation and distribution of the PHA document, and the development of intervention and prevention strategies. Two types of formal community participation groups that ATSDR has established are Community Assistance Panels (CAPs) and Federal Advisory Committee Act (FACA) committees with subcommittees. Contact CIB if more information is needed than the summaries below provide.

4.4.3.2 Community Assistance Panels (CAPs)

A CAP is a group of people, both community members and ATSDR staff, who meet regularly to (1) share environmental and health information about a specific site that may be environmentally contaminated and (2) assist ATSDR in making public health decisions that could affect the lives of community members. Factors that influence whether ATSDR decides to form a CAP at a particular site include: the degree of community interest, whether varying viewpoints exist regarding the health issues, and a willingness on the part of the public to actively participate in the process. CAPs have been established by ATSDR at seven sites during the last decade. For more information about CAPs, see http://www.atsdr.cdc.gov/HAC/caps.html.

4.4.3.3 Federal Advisory Committee Act (FACA) Committees

Under the Federal Advisory Committee Act (FACA), federal government agencies can convene committees to provide consensus advice and recommendations. FACA committees must meet the requirements of the Federal Advisory Committee Act. They are much more resource-intensive than CAPs and they require a much greater time commitment on the part of community members than CAPs. ATSDR has used FACA committees only in rare situations where sufficient resources are available and community members have indicated a very strong interest in providing consensus advice to the agency. A health communication specialist on your team, or at CIB, can provide more information on FACA committees.

4.4.4 Fact Sheets and Other Materials

Health assessors need to share newly learned information with the community in a timely manner. As such, you may disseminate information to the community in the form of fact sheets and other materials throughout the public health assessment process. Materials may need to be translated into another language for some of the community members. In some cases, you may choose to establish a Web site to disseminate and even collect site information. This method should only be considered if recommended by the community and in settings where access to or use of computers is known to be prevalent.

Fact sheets and flyers are probably the most frequently used materials. Sometimes letters are prepared to individual community members when a more personal format is needed, such as when requesting community members to participate in an exposure investigation or providing results of sampling on their property. Articles may also be prepared for newsletters published by community groups or other government agencies.

4.4.4.1 General Fact Sheets

Several general (not site-specific) fact sheets are available that can assist you in introducing the community, the media, and other stakeholders to ATSDR and its mission and work. The fact sheets can be distributed as is, or pertinent information can be excerpted to place in site-specific fact sheets as needed. The fact sheets can be mailed out to familiarize the recipients with the information prior to a meeting or they can be given out at the meeting. Only the fact sheets that are pertinent to the specific site should be distributed.

The following fact sheets can be obtained through CIB, ATSDR's Visual Information Center, or over the Internet. When requesting fact sheets, it is important to allow enough time so that copies can be printed if necessary.

• About ATSDR—provides general information about ATSDR and an overview of some of its programs and its work with communities; tribes, and local, state, and federal agencies.(http://www.atsdr.cdc.gov/COM/about.htm)
  
  
• What you can expect from ATSDR—explains ATSDR's mission and describes what ATSDR can and cannot do based on its legal authority. (http://www.atsdr.cdc.gov/COM/whatyou.htm)
  
  
• Get information from and about ATSDR—explains information available from ATSDR and how to contact ATSDR by web site, phone, fax, email, or writing. Additional information is available at ATSDR's Information Center.
  
  
• Agency overview—describes the various activities conducted by ATSDR, including public health assessments, health studies, toxicological profiles, health education, and several more.
  
  
• Community assistance panels—describes why and how a community assistance panel is established when community members prefer more direct participation in ATSDR's work in their neighborhood—beyond the usual community involvement activities.(http://www.atsdr.cdc.gov/HAC/caps.html)

Additional fact sheets are available that describe ATSDR activities that may be occurring in the site community. For example:

• Public health assessment—describes what this evaluation considers, the types of information that it evaluates, and how the evaluation is used. It also includes information about how the community can get involved in the process. (http://www.atsdr.cdc.gov/HAC/pha.html)
  
  
• Health consultation—describes what this type of evaluation considers, the types of information that it evaluates, and how the evaluation's recommendations are used. (http://www.atsdr.cdc.gov/HAC/consult.html)
  
  
• Petitioned public health assessment—describes how community members can ask ("petition") ATSDR to evaluate an environmental site. (http://www.atsdr.cdc.gov/HAC/petition.html)
  
  
• Exposure investigations—describes how an exposure investigation is one approach ATSDR uses to develop better characterization of past, current, and possible future human exposures to hazardous substances in the environment and to evaluate existing and possible health effects related to those exposures more thoroughly. (http://www.atsdr.cdc.gov/HAC/expinfaq.html)
  
  
• Public health advisories—describes how ATSDR evaluates and responds to a hazardous substance release into the environment that poses an immediate and significant danger to people's health. (http://www.atsdr.cdc.gov/HAC/healthad.html)

4.4.4.2 Site-Specific Fact Sheets (Newsletters)

Fact sheets are one of the ways ATSDR site teams provide communities with site-specific information.⁽¹⁾ Usually, fact sheets briefly introduce the reader to ATSDR, summarize the information that ATSDR currently knows about the site, and describe ATSDR's current and future plans for the public health assessment process, including plans to meet with the community. They can also be used to inform the community about the availability of a report (PHA, PHC) and how to obtain a copy. Fact sheets can be mailed out to familiarize the recipients with information prior to a meeting or they can be given out at a meeting. They can also be used to update communities between community meetings.

Fact sheets can be prepared in a variety of ways, often dependent upon how much preparation time is available. Generally the quality of the product is higher if sufficient time is available for the preparation. Work with the health communication specialist on your team when planning for and developing fact sheets.

4.4.4.3 Site-Specific Flyers (Meeting Announcements)

Flyers are one page (or one card) meeting announcements that are distributed to community members and other stakeholders. The agency has found that, for most sites, this is the most effective way to notify the community about a meeting. Sometimes community members or other stakeholders assist in the distribution, either via door-to-door distribution or by leaving the flyers in public locations, such as libraries, post offices, or grocery stores. The flyers contain information about the type of meeting and the agenda, the meeting location, and any background information that might be helpful and serve to encourage the recipient to attend. The health communication specialist and lead health assessor are often listed as contacts via ATSDR's toll-free number.

4.4.5 Media Support

The media, including local newspapers and radio and television stations, are an important communication resource for the site team. ATSDR's need for timely, cost-effective distribution of information to the public often complements the media's need for interesting material to publish or broadcast. ATSDR's site teams often provide information to the media by issuing press releases, by holding media sessions, or by providing or requesting interviews. However, the site team cannot be sure if and when the information will be disseminated or what the media will specifically report. The team may also submit a public service announcement, but cannot always be sure if and when the information will be disseminated. Occasionally ATSDR may pay for advertising. When using this approach, the site team is able to control what information is disseminated to the public and when.

ATSDR is required to submit press releases to the media whenever a public meeting is held or when a public comment or final report (e.g., PHA, PHC) is released. Other types of information are provided to the media as needed on a site-by-site basis.

4.4.6 Establishing Information Repositories

During the initial stages of the public health assessment process, ATSDR establishes information repositories at convenient locations (e.g., public libraries) within the community. These repositories will be used to house copies of important site-related documents, including PHAs. At many sites, the repository is co-located with EPA's, the tribe's, or the state's information repository. The distribution channels described above can be used to publicize the existence and location of the information repositories.

4.4.7 Access to Experts and Toll-Free Hotline

Community members and others reading public health assessment documents may need to talk to specialists to help clarify specific issues and decisions. You should establish a main point-of-contact within ATSDR who can refer residents to appropriate staff or other experts to answer their questions. Residents should be made aware of ATSDR's toll-free hotline (1-888-42-ATSDR) and should be provided with other contact information to facilitate two-way communication. Other vehicles for communities to access information include ATSDR's Web site (http://www.atsdr.cdc.gov) and its community involvement email address (atsdrcib@cdc.gov).

4.5 Including Community Involvement Activities in the Public Health Assessment Process

Community involvement and health communication activities, based on the strategies developed by the site team, are an important component of the public health assessment process, but will vary from site to site. Table 4-3 shows the types of community involvement activities that could be implemented at a site during various stages of the public health assessment process depending on site-specific issues.

ATSDR's involvement is different (low, medium, or high involvement) for the three site examples in the table. The levels shown are only examples of community involvement activities that may be conducted at sites. Activities for a specific site may vary in type and in when they are conducted during the public health assessment process.

Table 4-3. Activities That Might Be Conducted at Three Different Levels of Community Involvement and Participation

Phase of Public Health Assessment Process	Community Involvement Activities and Information
	Low Involvement Site	Medium Involvement Site	High Involvement Site
Initial data gathering about community from petitioner(s) (if a petitioned site); community leaders; local, state, tribal, and federal agencies; local media (See Chapter 3)	Results of data gathering: 1) Few, if any, community members are interested, or 2) Collection of community health concerns has been coordinated with other agencies. Establish repositories.	Results of data gathering: Some community interest seems to exist. Establish repositories.	Results of data gathering: High level of community interest, political interest, and/or high likelihood of exposure identified. Establish repositories.
Initial interaction/meeting(s)(2) with community	No meeting is held. Additional information may be gathered to ensure there is no community interest, even in small segments of population.	Usually at least one meeting(2) held (usually a public availability session) to gather community health concerns and other information. Preparation of mailing list. Notification of meeting via flyers, press release.	Multiple community meetings(2) held in coordination with local, state, tribal, and federal agencies. Local, state, tribal and/or congressional briefings. Media sessions and interviews. Preparation of mailing list(s). Notification of meetings via flyers, press releases, advertisements, etc.
Compiling and determining how to address community health concerns	If no community health concerns are identified, note the community involvement efforts taken to determine the concerns. This information will be included in the PHA.	Compile the community's concerns into at least three categories: 1) health concerns, 2) environmental concerns, and 3) other concerns. Plan how ATSDR will address each concern. Some concerns may need to be referred to another agency, such as work-related concerns. Whenever possible, notify community members at this time, if their concerns are beyond the scope of ATSDR's mission.	Compile the community's concerns into at least three categories: 1) health concerns, 2) environmental concerns, and 3) other concerns. Plan how ATSDR will address each concern. Some concerns may need to be referred to another agency, such as work-related concerns. Whenever possible, notify community members at this time, if their concerns are beyond the scope of ATSDR's mission.
Planning evaluation methodology to determine effectiveness of public health assessment activities	Minimal evaluation efforts: 1) Professional judgement. 2) Reader's survey that is included with documents.	In addition to low level: 3) Community feedback on logistics of meetings (does not require Office of Management and Budget [OMB] clearance). 4) Evaluation of indices of community participation (e.g., attendance at meetings, calls to ATSDR, requests for information).	In addition to low and medium levels: 5) Additional surveys that measure a) increased level of community participation and community satisfaction; b) improved responsiveness and relationships with community members/groups; and c) short- and long-term impact of ATSDR's work on community's health and quality of life. Note: Any surveys conducted via mailing or telephone will need OMB clearance.
Participation of community in the public health assessment process (Note: ATSDR determines the level at which the community would like to participate via interviews with community members and others, actual participation rates, etc. The level of interest may change over time.)	Ways the community might participate: 1) Contact ATSDR as notified in press releases. 2) Provide comments on ATSDR's reports (e.g., PHAs, PHCs).	In addition to low level participation, the community might: 3) Attend meetings and provide health concerns. 4) Contact ATSDR to get on mailing list. 5) Encourage other community members to attend meetings and provide health concerns.	In addition to low and medium levels of participation, the community might: 6) Indicate that they would like more direct participation. 7) Discuss best ways to enhance community participation with ATSDR. 8) Consider forming a community group or ask ATSDR to work with one already established by community. Each site community has specific needs and interacts differently. ATSDR responds to all reasonable requests, continually reminds the community what they can expect from ATSDR, and prioritizes community involvement activities at the site based on available resources.
Community involvement activities conducted during evaluation of environmental and health data and other information.	None	Update community one or two times via distribution of fact sheet.	Provide more frequent updates (e.g., quarterly via community meetings, through distribution of fact sheets, through newsletters). Conduct various public health activities during evaluation, such as health education, community workshop, an exposure investigation, the release of a public health advisory
Community involvement information/assistance included in document (PHA and other documents as needed) For all sites, include the following: 1) Document community involvement activities. 2) Respond to community health concerns in a clear and concise way. 3) Work with health communication specialists, as necessary, to ensure language in the Summary, Conclusion, and Recommendation sections is suitable for the site-specific audience (see also Section 4.2.5 and Appendix C).	In addition to 1-3 include: 4) Efforts to find community members concerned about site. 5) How community health concerns were obtained. 6) Location of information repositories.	In addition to low level include: 7) Community involvement activities conducted to involve community members and their participation. 8) How community was informed of meeting(s) and other community involvement activities, including the use of electronic media. 9) Any pertinent coordination efforts with community groups, other organizations, the media, and other government agencies.	In addition to low and medium level, include: 10) Community involvement activities conducted to enhance participation by community members and their response. 11) How ATSDR interacted with community groups, either those already formed or newly established with ATSDR's help. 12) How community members participated in planning, assessment, and intervention activities. 13) Indications of mutually beneficial partnership with community, organizations, and other government agencies.
Community involvement activities conducted during distribution of document (e.g., PHA, PHC, Exposure Investigation) for public comment, if applicable, and then later as final document.	Press release. Copy of document placed in repositories.	Press release. Notification of distribution via flyers or a fact sheet explaining location of document in repositories and also how to obtain a copy of the document from ATSDR. A community meeting if there is enough community interest. Copy of document and accompanying summary fact sheets (if prepared) placed in repositories.	Press release. Notification of document distribution via flyers and/or fact sheets/newsletters, press releases, advertisements, etc. Coordination with local, state, tribal, and federal agencies. Local, state, tribal, and/or congressional briefings. Media sessions and interviews. Community meeting(s). Notification of meeting(s) via flyers, press releases, advertisements, etc. Copy of document and accompanying summary fact sheets placed in repositories.
Community involvement activities conducted during implementation of recommendations in PHA or PHC, such as additional assessments, a health study, or an exposure investigation.	Dependent on the type of recommendations, the site, and the expressed needs of community members.	Dependent on the type of recommendations, the site, and the expressed needs of community members.	Dependent on the type of recommendations, the site, and the expressed needs of community members.

4.6 Community Health Concerns in Public Health Assessment Documents

During the evaluation phase of the PHA process, the site team investigates whether the site may be contributing to actual or potential health concerns of the community based upon careful examination of exposure and health data. When the PHA or health consultation is prepared, a section is included that responds to the community health concerns that the site team has gathered.

Community health concerns are typically introduced in the Purpose and Health Issues section of public health assessment documents. More detailed information is then presented in either a Community Health Concerns section or as a subsection of the Discussion section, whichever seems most appropriate for the overall flow of the document. The following information should be provided:

• What health concerns, including suspected exposures and health effects, the community has expressed.
  
  
• The nature and extent of efforts to learn about community health.
  
  
• How the health concerns may or may not relate to site-specific contaminants and exposures pathways.

Conclusions and public health recommendations about the community health concerns should be repeated in the Conclusions and Recommendations section of the document.

4.6.1 How to Respond to Community Health Concerns

Every site is unique in terms of the nature and intensity of community health concerns and the availability of data to respond to these concerns. Here are some factors to consider in responding to these concerns:

• The amount of detail appropriate for your response section will vary depending on the complexity of the issues involved and the public health implications. If there are numerous community health concerns, it is not necessary to answer each specific concern individually, but responses can be provided to common topics or issues. (An appendix that lists each comment organized by type of concern can also be included.) If there is little community interest in a site, it can be stated that few community concerns were found, and then information organized by exposure pathway can be presented. In general, the level of detail provided should be that which will best meet the needs or interests of the community.

• Some health concerns may not be related to contaminants at the site. Generally, a response to a health-related concern should be provided even if the contaminant in question was not detected at the site or was present but not found to pose a health hazard. If the health concern relates to a potential source off site, the response can simply note that the contaminant relates to an off-site rather than on-site source. When possible, residents should be referred to other agencies that may be able to provide information or assistance in addressing their concern. At sites where there is a high level of community concern about off-site sources, it may be appropriate to provide a more detailed response to these concerns.

• Since public health assessment documents focus on health issues, you might not want to respond to non-health issues such as certain environmental, property, or liability concerns unless they are in some way related to public health. At a minimum, acknowledge that such concerns were voiced, but that they are beyond the scope of the public health assessment. The site team may direct the concern or inquiry to an appropriate local, state, or federal agency.

4.6.2 How to Present Responses to Community Concerns in the PHA

When developing the section on community concerns and ATSDR responses, you should follow the principles of effective communication described in Section 4.2.5 and Appendix D—that is, you should present the information with clarity, accuracy, respect, and sensitivity.

Respect includes presenting community concerns as they were expressed by the community, without evaluating the concerns. To protect privacy, you should not name the individuals who expressed concerns, although you can name community groups that have raised concerns.

To make the concerns and your responses easier to understand, you might want to present the community concerns as questions posed by the community to ATSDR. For example: "Is the well water in Grant Acres neighborhood safe to drink?" or "Can breathing air from the site cause skin rashes?" Your responses can summarize the evaluation results that answer the question and then can refer the reader back to information discussed previously in the document (e.g., discussions on exposure pathways, toxicologic information). You can briefly summarize the information from other sections if this will help clarify the point you are trying to make, but you should not repeat other sections of the report in their entirety.

4.7 Public Comment Process and Release of Final Public Health Assessment Documents

Once you have assembled a draft document, you may wish to distribute it for review by other public agencies and stakeholders to make sure the data are accurate, current, and complete, and that your conclusions and recommendations are clearly presented and well documented. For PHAs, this is often referred to as the "initial release" or "data validation" PHA. The next step for PHAs is a formal public comment process, described below. (Note: For public health consultations, public comment is not required but can be useful, particularly at sites with a high level of interest or concern. Also, excluding interested community members can potentially foster mistrust.)

4.7.1 Public Comment Process

The public comment process gives the public—particularly the community near the site—an opportunity to review the results of the public health assessment and the agency's conclusions and recommendations, and to provide additional information and comments. In their review of the document, members of the community may provide input on such issues as: Is the document clear and understandable? Has ATSDR taken into account all relevant site information known to the community? Has the agency identified and responded to the community concerns? See also Appendix C (Community Check List).

If ATSDR receives public comments, you will need to consider making revisions to address those comments. You will also need to prepare an appendix for inclusion in the final PHA that presents formal agency responses to all public comments received. After reviewing the comments and making revisions as needed, ATSDR will release the document as a final PHA. The public comment process proceeds through three distinct stages, as described below.

4.7.1.1 Releasing the Draft PHA

The first step in the public comment process is the release of the draft document to the public. To help encourage community members to read and comment on the document, you can develop a simple concise summary (e.g., a fact sheet) describing the PHA's main findings and distribute this summary together with the draft PHA. The summary should capture key findings and recommendations, including public health actions. Communication experts have suggested to ATSDR that the writing should be simple and at a sixth-grade reading level. Health communication strategies developed during the PHA process should influence how you prepare your document. Appendix D provides an example of this type of PHA summary fact sheet.

Proper distribution and publicity are critical to an effective release. You should use a number of mechanisms to get the draft document and summary into the hands of interested community members and to let them know the deadline for receipt of comments and where they should send their comments. Depending on resources and appropriateness, release and publicity mechanisms may include the following:

• Place copies of the draft document and extra summaries for people to take home in all local ATSDR and EPA information repositories.
  
  
• Provide a copy of the public health assessment to EPA, the state health agency, and any other agencies that have an interest or have been involved with the site.
  
  
• Use your mailing lists and community contacts to send the draft document and summary to all interested parties, including local health departments and community organizations and leaders. If mailing lists are large, you can send a notice, or a fact sheet summarizing the findings, to everyone on the list and ask anyone interested in obtaining a copy of the draft document to request one.
  
  
• Announce the availability of the document in a press release to local media.
  
  
• Hold a public meeting a few weeks before the document is released, or during the comment period, to further publicize the availability of the document and to encourage community members to review and provide their comments.
  
  
• Send letters or flyers about the document to key community contacts and to school, faith, or civic organizations, as appropriate.
  
  
• Consider using e-mail as a distribution vehicle in communities where many people have Internet access. Be sure to also make hard copies available to people without Internet access through the mechanisms described above.

4.7.1.2 Receipt of Public Comments

The deadline for receiving comments is usually printed on the cover of the draft PHA. Typically the public is given at least 30 calendar days from the official release date of the document to comment. However, you may decide to extend the public comment period as appropriate to ensure that all interested parties have a reasonable opportunity to comment.

4.7.1.3 Responding to Public Comments

Once the public comment period has ended, you should meet with the other site team members to determine how the agency will respond to each comment. In responding, the team may decide to make a change to the document or—with appropriate rationale—not to make a change. Changes in factual information, such as measurements of contaminant levels, should be supported by valid data. As in any review of scientific documents, when a reviewer identifies what they believe to be factual errors in the draft document, the authors may request valid data or information from the reviewer before making corrections in the document.

As described in Chapter 2, the agency's responses to comments must be summarized in an appendix in the final PHA. The structure of the appendix depends on the number and nature of the comments received. Consider the following factors when compiling and responding to public comments:

• Do not identify the commenter(s) (e.g., individual names or private organizations) when presenting the comments. Provide a brief introduction to the appendix describing the number of comments received from various entities. For example: "ATSDR received a total of 60 comments from a number of parties, including the U.S. Environmental Protection Agency, state health and environmental agencies, community groups, and individual community members."
  
  
• Package comments and responses in a way that will maximize readability and best meet the information needs of your audience. For example, a tabular format can work well when presenting a large number of comments: it is sometimes easier to read a table that presents each comment and response side by side.
  
  
• Group similar comments together by topic or theme. This will produce a more streamlined presentation of comments and help to lay out the logic behind ATSDR responses. Also, where possible, summarize comments expressing the same question or concern.
  
  
• If the comment is succinct and clear, present it verbatim. This will minimize the chance of miscommunicating or misinterpreting the comment. But use some judgment in discerning the need to edit comments for content, length, or both (e.g., separate out distinct points, condense to eliminate redundancy). In all cases, accurately mine the essence of the issue and present it clearly.
  
  
• When responding to comments, focus on addressing technical issues related to the public health assessment process or to the PHA's conclusions. Because response to public comments can be time- and resource-intensive, maintain your focus on public health issues. Acknowledge comments that are not specific to site-related public health issues, but explain that the comment is beyond the scope of the public health assessment. In some cases, you may refer the reader to another agency or group for additional answers.

When considering whether and how to respond to public comments—especially those comments that contain arguably inflammatory statements—remember that in addition to the public comment section of the appendices, a log of all comments received is kept with the official site file as part of the site administrative record. The administrative record is available for public inspection upon written request.

4.7.2 Release of Final PHA or PHC

Once the PHA or PHC is final, you should place a copy of the document (and the document summary if you have developed one) in all ATSDR and EPA information repositories. You can also disseminate the main findings to the community via press releases, newsletters, and/or e-mail.

You should also meet with the other site team members to determine whether a public meeting is needed to announce the results of the PHA. If a public meeting is to be held, be prepared to discuss your responses to public comments, future activities, and other issues associated with the PHA. Criteria for determining whether a public meeting is needed at this point in the process include:

• The number of comments received (an estimate of community interest).
  
  
• The advice of community members who have been active in the process.
  
  
• Input from key community contacts and the larger community, as indicated in meetings or by telephone.
  
  
• The amount and type of media coverage.
  
  
• History of community interest (estimated by the number of community-based environmental groups, the number of people visiting the information repository, or calls to ATSDR staff from the community).
  
  
• The number of people who have attended past meetings.

4.8 Disseminating Information to the Community

Throughout the public health assessment process you will be readying information for release to the public. Several procedures related to the dissemination of information are required or strongly recommended to ensure consistent products are disseminated and in a timely and efficient manner.

ATSDR has found that direct mail is usually the most effective distribution channel to publicize and disseminate information to specific site communities. Advertisements via local newspaper and media outlets have also been used effectively, except they are usually much more expensive than direct mail distribution. Other distribution channels can include newsletters or e-mail lists of local organizations or community associations, and bulletin boards (e.g., at stores and supermarkets). The media can also be an important means for disseminating information to the community (see Section 4.4.5).

4.8.1 Developing Mailing Lists

To conduct mailings through direct mail, you must first have a mailing list to use. Different sources of mailing lists may include:

• Mailing list from another government agency that has been working at the site.
  
  
• List of addresses created by GIS—a list of addresses can be determined based on an geographic area at or near the site (e.g., within a ½ mile or 1 mile radius of the site).
  
  
• List of addresses from U.S. Postal Service.
  
  
• Names and addresses of attendees at community meetings from sign-in sheets.
  
  
• Other local sources including: local utilities, county tax maps, community group membership lists, and mailing lists created by community members through neighborhood surveys.

Because some of the community members that ATSDR works with may not have access to or be able to use a computer, e-mail mailing lists have seldom been used.

4.8.2 Clearance Procedures

To ensure the quality of ATSDR's external communication, the agency requires that all public information products be cleared for policy, scientific and technical accuracy, propriety, necessity, appearance, format, and editorial quality before release. This mandatory clearance process ensures that all persons associated with and responsible for the material agree with its content and format. All outreach materials, as well as the PHCs and PHAs, must be cleared by the director of the originating division or office (or by their designee). In addition, clearance by other offices may also be necessary. For example, clearance by the Office of Communication is typically required for all media-related materials (e.g., press releases, interviews, letters to editors, editorial boards, public service announcements, Web news postings, media sessions, and advertisements).

When the material is ready for release, the author must obtain clearance for each item by filling out ATSDR's clearance form CDC 0.576. Reviewers initialize the form to document their review and clearance. ATSDR's mandatory clearance policy is described in detail in Policy Guideline: Clearance of Informational Material (ATSDR 2000).

References

ATSDR. 2000. Policy guideline: clearance of informational material. Atlanta: US Department of Health and Human Services.

ATSDR. n.d. A primer on health risk communication principles and practices. http://www.atsdr.cdc.gov/HEC/primer.html.

Other Resources

ATSDR. n.d. A primer on health risk communication principles and practices. Agency for Toxic Substances and Disease Registry. http://www.atsdr.cdc.gov/HEC/primer.html.

Provides a framework for the communication of health risk information to diverse audiences. Discusses issues and guiding principles for communicating health risk and provides specific suggestions for presenting information to the public and interacting effectively with the media.

ATSDR. 1997. An evaluation primer on health risk communication programs and outcomes. Agency for Toxic Substances and Disease Registry. http://www.atsdr.cdc.gov/HEC/evalprmr.html. Can be used to facilitate planning evaluations for risk communication programs. The primer informs decision-makers about what should be communicated, in what form, to whom, and with what expected outcome; identifies performance indicators; and provides guidance on how to use target audience ideas and opinions effectively to shape the risk communication message.

Chess C, Hance BJ, Sandman, PM. 1991. Improving dialogue with communities: a risk communication manual for government. Summarizes practical lessons for communicating about environmental issues. Available from the Center for Environmental Communication (CEC) http://aesop.rutgers.edu/~cec/ at Rutgers University.

EPA. 1991. Air pollution and the public: a risk communication guide for state and local agencies. Air Risk Information Support Center. Research Triangle Park, North Carolina. EPA 450/3-90-025. Provides examples of effective methods in presenting public health risk information to the public.

ATSDR and the National Association of County and City Health Officials (NACCHO). Assessment to Action: A Tool for Improving the Health of Communities Affected by Hazardous Waste. Provides steps and methods to assess community needs and concerns related to hazardous waste sites. Copies are available from NACCHO,1100 17th Street, Second Floor
Washington, DC 20036 (202) 783-5550, or at www.naccho.org.

National Association of County and City Health Officials (NACCHO). Don't hazard a guess: addressing community health concerns at hazardous waste sites. A practical hands-on guide. Copies are available from NACCHO,1100 17th Street, Second Floor
Washington, DC 20036 (202) 783-5550, or at www.naccho.org.

National Research Council. 1989. Improving risk communication. Washington, DC: National Academy Press; 1989. Provides guidance about the process of risk communication, the content of risk messages, and ways to improve risk communication.

Pereira G, Patterson MB, Lybarger J. 2000. Use of citizen panels to enhance community involvement in environmental public health actions at ATSDR. Environ Epidemiol Toxicol (2000)2(2-3):74-8. Provides information about effective interaction with community assistance panels.

Williams, R.C., M. Lichtveld, S. O. Williams-Fleetwood, and J.A. Lybarger. 2000. Communities at the center: in response to community concerns at hazardous waste sites. Environ Epidemiol and Toxicol (2000)2:56-66. Highlights ATSDR's philosophy pertaining to effective community involvement.

Online Resources

American Industrial Hygiene Association (AIHA) Founded in 1939, AIHA is an organization of more than 13,000 professional members dedicated to the anticipation, recognition, evaluation, and control of environmental factors arising in or from the workplace that may result in injury, illness, impairment, or affect the well-being of workers and members of the community. As part of a continuing education program, AIHA offers an Effective Risk Communication Training Series. http://www.aiha.org.

California State University at Northridge (CSUN) The Risk Communication Forum provides links to key sources of environmental health risk information and to fellow professionals in the environmental health community. http://www.csun.edu/~vchsc006/tom.html#Introduction.

The Center for Environmental Communication (CEC) at Rutgers brings together university investigators to provide a social science perspective on environmental problem-solving. CEC (formerly the Environmental Communication Research Program) has gained international recognition for responding to environmental communication dilemmas with research, training, and public service. http://aesop.rutgers.edu/~cec/.

The Center for Environmental Information (CEI) is a private, nonprofit educational organization founded in Rochester, New York, in 1974. CEI's Environmental Risk Communication Program offers training, resources and skills to enable all parties involved in an environmentally risky situation to work together toward a mutually acceptable outcome. http://www.rochesterenvironment.org.

University of Cincinnati Center for Environmental Communication Studies The mission of the Center is to enhance the understanding and quality of communication processes and practices among citizen, industry, and government participants who form and use environmental and health policies. http://www.uc.edu/cecs/cecs.html.

The University of Tennessee College of Communication and Information offers seminars on risk communication. http://excellent.com.utk.edu/.

The National Partnership for Reinventing Government has developed a guidance document, Writing User-Friendly Documents, to help writers avoid producing complicated, jargon-filled documents. http://www.plainlanguage.gov.

Hotline

Risk Communication Hotline. Responds to questions on risk communication issues and literature, provides information on EPA's Risk Communication Program, and makes referrals to other related agency sources of information. 202-260-5606, Monday through Friday, 8:30 a.m. to 5:00 p.m., E.S.T.

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¹ All site-specific fact sheets must be included in the site file.
² Community meetings can refer to any of the various types of meetings ATSDR might conduct with the public (e.g., public availability sessions [individual community member interviews], poster sessions, public meetings, community group meetings).