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Name: Date:
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Tribal Affiliation: Survey #:
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Checklist: Please review the checklist and share the level of concern you may have for each climate change issue.
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If there are any climate change effects that are not listed here, please provide them in the empty spaces below.
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RISING TEMPERATURE No Concern Slight ConcernSome ConcernMajor Concern Not Applicable
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Greenhouse Gas Pollution
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Food production in agriculture 
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Livestock producing methane and nitrous oxide
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Deforestation & urbanization
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Burning of fossil fuels - coal, gas, car exhaust
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Industry & manufacturers producing pollutants
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Changes in weather patterns 
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Rising River and Stream temperatures
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WATER SUPPLY (Decline due to snowpacks)No Concern Slight ConcernSome ConcernMajor Concern Not Applicable
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Declining Water Supply
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Reduced stream flows
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Ocean Deoxygenation
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Reduced seasonal water in streams and rivers
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Evapotranspiration
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Ground Water Depletetion
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Harmful Algal blooms
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Reduced water quality in local waters
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Avalanches
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Drought 
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Reduced drinking water supply
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Reduced drinking water quality
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Water supply infrastructure dapting to climate change (i.e. dams, leevees, plumbing, water cleansing systems)
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Pressure from outside agencies or entities to move water from natural systems (i.e Delta Conveyance Tunnels)
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WILDFIRENo Concern Slight ConcernSome ConcernMajor Concern Not Applicable
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Raging wildfire(s)
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Cost of rebuilding
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Smoke
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Airborne Allergen Exposure
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Lung/Heart Diseases
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Toxins/Chemicals used in fire repression 
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Loss of infrastructure due to wildfires (i.e. roads, buildings, etc.)
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Barriers to Traditional / Cultural burns
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SEA-LEVEL RISE No Concern Slight ConcernSome ConcernMajor Concern Not Applicable
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Melting Glaciers
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Ocean warming
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Red-Tide
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Coastal Erosion
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Coastal flooding 
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Flooding
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Soil Erosion
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Infrastructure damage
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High-tide events 
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Storm Surge 
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Rising Tides
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Tsunamis
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Ocean acidification
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Salt water intrusion (wetlands/rivers/ streams)
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COMMUNITIES No Concern Slight ConcernSome ConcernMajor Concern Not Applicable
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Loss of public transportation infrastructure
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Evacuation during emergencies
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Loss of cultural resources & threats to cultural continuance
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Unable to practices traditions - loss of cultural resources, and medicines
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Unable to access cultural sites
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Loss of traditional foods
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Unable to access traditional foods (food does not grow locally)
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Loss of housing due to rising costs
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Loss of housing due to natural disasters
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Loss of community spaces due to natural disasters (e.g gathering locations, natural landscapes, parks, schools, governmental, health and admin buildings)
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Loss of telephone/satellite infrastructure (e.g cellphone towers, power lines, water/electricity) 
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Rising cost of food
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Concerns of foodborne illnesses (i.e. Salmonella, Listeria)
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Pollution
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Ocean Pollution
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Garbage/Liter Pollution
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Plastic Pollution
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Water Pollution
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Air Pollution
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Toxic Spill Pollution
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Soil Pollution
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Landslides and Mudslides
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Hail/Ice Storms
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Please list any Species of concern:
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