Followback I

ATTACHMENT K OMB 0920-00260

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

Final Report

The National Institute for Occupational Safety and Health (NIOSH) conducts surveys of people with whom we have communicated in responding to Health Hazard Evaluation requests. 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. We are interested in your experiences and thoughts about the NIOSH response. Please help us by filling out this survey form. We may send you another survey in approximately one year, asking about implementation of the recommendations that NIOSH made. Your responses will be kept in a confidential 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 10 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: Final Report
This survey asks your thoughts about the recently completed NIOSH health hazard evaluation. 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 you talk to a NIOSH investigator about your request for a health hazard evaluation?		yes no
Did the investigator give a satisfactory explanation of why NIOSH would not do an onsite evaluation?		yes no I did not talk to a NIOSH investigator
Did NIOSH issue its report in a reasonably short time after you requested the health hazard evaluation?		yes no don’t know
Did you read the report?		yes no – Skip to question 14, page 2 don’t know
What is your overall impression of the report?		excellent good fair poor
What are your thoughts about this statement? The report was helpful to me.		strongly agree mostly agree mostly disagree strongly disagree
What are your thoughts about this statement? I understood the report’s technical information.		strongly agree mostly agree mostly disagree strongly disagree
On balance, do you think the recommendations the NIOSH investigators made were appropriate?		yes no no recommendations were made
On balance, do you think the recommendations the NIOSH investigators made were practical?		yes no no recommendations were made
Did you share the NIOSH report with your supervisor or another manager?		yes no
Did you share the NIOSH report with employees who are neither supervisors nor managers?		yes no
If NIOSH suggested contacting another agency or organization for assistance, did you or anyone else do that?		yes no don’t know no suggestion was made
What is your overall impression of the NIOSH health hazard evaluation?		excellent good fair poor
Would you request a NIOSH health hazard evaluation again if you were concerned about a possible health hazard in your work place?		yes no don’t know
Please print here any comments that you have about the NIOSH health hazard evaluation.
Which one of the following best describes your position at the work place now?	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: __________________________
Will you be part of decision-making related to the NIOSH recommendations?	yes, and I have final authority yes, somewhat no no recommendations were made
One year from now we may send you one more survey about the NIOSH health hazard evaluation. 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 the next survey 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 2A (9/07) 6