1. 1. Group number

   This is your designated group number. Please email adoptaspot@kabc.wa.gov.au if you do not know yours

2. 2. Date of cleanup
3. 3. Name of Coordinator
4. 4. Name of group (if applicable)
5. 5. Site name
6. What local government area do you live in?
7. 6A. Number of participants- ADULTS
8. 6B.Number of participants-CHILDREN
9. 7. Approximate number of minutes at the site.*

   This number will be used to estimate total volunteer time at the site.

10. 8A. Were there any incidents or injuries to participants ? noyes
11. 8B. If yes give details.
12. 9. Number of orange litter bags filled
13. 10. Number of shopping bags filled

    For those who pick up small amounts of rubbish using plastic shopping bags

14. 11. Did you separate rubbish from recyclable litter items? YesNo

    If yes, please complete next section, Q 11,12,13,14

15. 12. How many of these bags were for rubbish only
16. 13. How many of these bags were for recyclable material only?
17. 14. Approximate weight in KG of rubbish bags
18. 15. Approximate weight in KG of recyclable materials
19. 16. Total weight in KG of rubbish picked up(recyclables and rubbish)
20. 17.If you picked up green waste, please estimate how many bags?(otherwise skip this question)
21. 18. If you picked up cigarette butts, please estimate how many? (otherwise skip this question)
22. 19. If you picked up used syringes, please record how many?(otherwise skip this question)

20. Did you pick up any of the following items (please tick for yes)

Aluminium cansglass bottlespaper/cardboardplastic bottles

23. 21. If you recycled any aluminium cans, please estimate how many.

    Please include whether they are single items or bags

24. 22.If you recycled glass bottles, please estimate how many.
25. 23. If you recycled paper or cardboard, please estimate what quantity.
26. 24. If you recycled plastic bottles, please estimate how many.
27. 25. Other comments or unusual items found:

28. Photos

    Please take some photos of your group participating in the clean up for us to use to promote the Adopt-A-Spot Program to other people in the community. Email them to adoptaspot@kabc.wa.gov.au

* denotes a required field.