Initial Site Visit Survey Form

ATTACHMENT H OMB #0920-0260

Expir._____

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

U.S. PUBLIC HEALTH SERVICE

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

Health Hazard Evaluation Survey

Initial Site Visit

The National Institute for Occupational Safety and Health (NIOSH) conducts surveys of people at each work place who are involved in NIOSH evaluations. We use the information from these surveys to improve our procedures and reports and to learn about the effects of NIOSH evaluations in reducing and preventing work-related illness and injury. Please help us by filling out this survey form.

Even though this NIOSH evaluation is not completed, we would like to learn your experiences and thoughts about it thus far. We will send you follow-up surveys two more times in the future: after the health hazard evaluation is completed, and again approximately one year after its completion.

Your responses will be kept in a secure manner according to applicable laws. Our reports will include only summary information and will not identify you in any way.

Please mail completed surveys to NIOSH in the postage paid envelope. If you have any questions or concerns, please call Barbara Jenkins at 513-458-7132.

Thank you!

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-0260).

STATEMENT OF AUTHORITY:

Sections 20(a)(3–6) of the Occupational Safety and Health Act (29 USC 669(a)(6–9), and Section 501(a)(11) of the Federal Mine Safety and Health Act (30 USC 951(a)(11). The identity of the participant will be protected under provisions of the Privacy Act (5 USC). The voluntary cooperation of the participant is required.

NIOSH Health Hazard Evaluation Survey: Site Visit
This survey asks your thoughts about the NIOSH health hazard evaluation thus far. Please fill in circles completely like this:
Do you think there is a health hazard at the work place now?	no hazard yes, a mild hazard yes, a moderate hazard yes, a severe hazard don’t know
Did NIOSH kept you well informed of the plans for the health hazard evaluation?	yes no, I wanted to know more no, but I didn’t need to know
Did NIOSH visit the workplace in a reasonably short time after the health hazard evaluation request was made?	yes no don’t know
In the opening conference discussions, were you fully able to express the issues as you see them?	yes no I did not attend there was no opening conference
At the end of the site visit, did the NIOSH investigators give a satisfactory summary of what they did?	yes no don’t know
At the end of the site visit, did the NIOSH investigators give a satisfactory description of future plans for the health hazard evaluation?	yes no don’t know
Do you think the NIOSH investigation is objective thus far?	yes no don’t know
Do you think the NIOSH investigation is thorough thus far?	yes no don’t know
Do you think recommendations NIOSH investigators have made thus far are appropriate?	yes no don’t know no recommendations were made
Do you think recommendations NIOSH investigators have made thus far are practical?	yes no don’t know no recommendations were made
What is your overall impression of the NIOSH health hazard evaluation thus far?	excellent good fair poor
Please print here any comments you have about the NIOSH health hazard evaluation thus far.
Did you request the health hazard evaluation?	yes no
Which one of the following best describes your position at the time of the NIOSH site visit?	no longer associated with the work place management health and safety staff union representative supervisory employee nonsupervisory employee government health/safety agent consultant other – please describe: _______________________________
We will send you two more surveys about the NIOSH health hazard evaluation, one after you receive the health hazard evaluation final report and another one a year later. So that we may contact you again, please make any corrections to the label below. Check this box if you would like to receive and respond to future surveys electronically. □ If we have not included your email address, please write it here: _____________________________________________________________________________
Thank you for taking the time to fill out this survey. We appreciate your cooperation. Please send this form in the enclosed envelope to: Barbara Jenkins, NIOSH R-9, 4676 Columbia Parkway, Cincinnati, OH 45226.

Form 1A (9/07) 2