HHE Request Form

Request for a Health Hazard Evaluation

Form Approved

This form also is available at http://www.cdc.gov/niosh/hheform.html

Exp. Xx/xx/2015

OMB No. 0920-0260

Workplace Name______________________________________________________________________________
Workplace Address ____________________________________________________________________________
Street
City
State
Zip Code
What type of work is done at this location? ________________________________________________________
How many people work at this location?
O 3 or less
O 4-9
O 10-49
O 50-99
O 100-249
O 250 or more
Who is responsible for employee health and safety in this workplace?
Name_________________________ Title___________________________ Phone number________________
What hazardous substances, agents, or work conditions are of concern? If known, please include chemical names, trade
names, manufacturer name, or other identifying information.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
How are employees exposed?
O Breathing
O Skin Contact

O Swallowing

O Other (Explain :____________________)

In what work area, such as a building or department, is the hazard? _______________________________________
How many people work in this area?
O 3 or less
O 4-9
O 10-49

O 50-99

O 100-249

O 250 or more

Describe the work people do in this area: ___________________________________________________________
_____________________________________________________________________________________________
What health concerns do people in this work area have? _______________________________________________
_____________________________________________________________________________________________

Information about you
Name (please print):_______________________________________________
Your signature: ___________________________________________________
Address _____________________________________________________________________________________
Street
City
State
Zip Code
Phone number where you would like to be called: (_____) __________________
Best time to call: _________________ a.m. or p.m.
Email address where you would like to be contacted: _________________________________________________
Please check one:
O I am a current employee and 3 or fewer employees are exposed to the hazard.
O I am a current employee and more than 3 employees are exposed to the hazard.
*If you check this box, two other employees need to sign this form and provide their contact information.
Public reporting burden of this collection of information is estimated to average 12 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).

Second employee
Name (Please print): _______________________________________________
Signature: ___________________________________________________
Address _____________________________________________________________________________________
Street
City
State
Zip Code
Phone number where you would like to be called: (_____) __________________
Best time to call: _________________ a.m. or p.m.
Email address where you would like to be contacted: _________________________________________________
Can NIOSH reveal your name to the employers?
O No
O Yes

Third Employee
Name (Please print): _______________________________________________
Signature: ___________________________________________________
Address: ____________________________________________________________________________________
Street
City
State
Zip Code
Phone number where you would like to be called: (_____) __________________
Best time to call: _________________ a.m. or p.m.
Email address where you would like to be contacted: _________________________________________________
Can NIOSH reveal your name to the employers?
O No
O Yes

Complete this section if you are a union representative
Name of union: ______________________________________________________________________________
Address: ___________________________________________________________________________________
Street
City
State
Zip Code
What is your position in the union: ______________________________________________________________

Complete this section if you are an employer representative
Name: _____________________________________________________________________________________
What is your position in the company, agency, or organization? _______________________________________

For everyone
Has another government agency evaluated this workplace?
O No
O Yes
O Do not know
If yes:
What agency? _________________________________________________________________________
What year was the evaluation done? _______________________________________________________
O Check here if this evaluation is underway now
Is a request for the hazard being filed with another agency?
O No
O Yes
O Do not know
If yes:
What agency? _________________________________________________________________________
How did you learn about the NIOSH Health Hazard Evaluation Program?
O NIOSH website
O Facebook
O other website (Explain :______________________________________)
O CDC 1-800 number O Union
O Coworkers O Company official
O trade/industry/union magazine or newsletter
O Other (Explain :________________________________)
If you have questions about this form, call us at (513) 841-4282 or send us an email at [email protected].
To submit this form by fax, send it to (513) 841-4488.
To submit this form by mail, send it to: National Institute for Occupational Safety and Health
4676 Columbia Parkway, MS R-9
Cincinnati, Ohio 45226
Thank you for submitting this form. You will get a response from us within 10 days.