2020 Online Green Chemistry Course Application

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* 1. Contact Information

Name: *

School: *

School Address: *

Address 2:

City/Town: *

State:

ZIP: *

Country:

Email Address: *

Phone Number: *

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* 2. Rate your previous experience and knowledge of green chemistry. (1-unfamiliar with topic, 2-aware of topic, 3-neutral, 4-knowledgeable 5-very knowledgeable)

1- unfamiliar

2- aware of topic

3- somewhat knowledgeable

4-knowledgeable

5- very knowledgeable

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* 3. Briefly describe your interest and expectations for the course.

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* 4. How would you rate your school's chemical storage practices?

Very unsafe and haphazard storage (there hasn't been a chemical clean-out in decades)

Unsafe and a handful of storage concerns

Could use improvements but overall hazards don't concern me

Safe and materials aren't always stored properly

Very safe and organized we had a chemical clean-out in the past 5 years

Very unsafe and haphazard storage (there hasn't been a chemical clean-out in decades)

Unsafe and a handful of storage concerns

Could use improvements but overall hazards don't concern me

Safe and materials aren't always stored properly

Very safe and organized we had a chemical clean-out in the past 5 years

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* 5. Would you be interested in learning more about local chemical clean-out offerings and programs for your school in your state?

Yes

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* 6. Please describe in 300 words or less what you’d like to bring back to your students as a result of this training.

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* 7. How did you hear about the online course?

State sponsored environmental protection agency

State science association

Higher education institution

NYS Master Teacher

colleague

social media

Beyond Benign

AACT

Other (please specify)