Follow-back no onsite Year 2

Attachment K:

One Year Later for HHEs without an On-site Evaluation-Followback Survey Cover Letter and Form

Form Approved

OMB No.: 0920-0260

Expiration Date:

Health Hazard Evaluation Program

One-Year Later Followback Survey

Health Hazard Evaluation Survey

Health Hazard Evaluation Survey

One Year Later

Health Hazard Evaluation Survey

One Year Later

Health Hazard Evaluation Survey

One Year Later

Health Hazard Evaluation Survey

One Year Later

Health Hazard Evaluation Survey

One Year Later

The National Institute for Occupational Safety and Health (NIOSH) surveys those who were involved with NIOSH health hazard evaluations. Now, one year after the close of the evaluation, we would like to know whether action was taken at the workplace and if there have been positive changes. Please give your candid answer to each question. Your survey responses will help us prevent and reduce work-related illnesses and injuries at workplaces across the nation.

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.

Thank you for taking the time to fill out this survey.

Please mail the completed survey to NIOSH in the enclosed postage paid envelope.

Call Barbara Jenkins at 513-458-7132 if you have questions about the survey.

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: One Year Later
This survey asks what has happened at the work place in the year since NIOSH completed the health hazard evaluation. Please fill in circles completely like this:
1. Do you think there is a health hazard at the workplace now?	No hazard Yes, a mild hazard Yes, a moderate hazard Yes, a severe hazard I don’t know
Do you think NIOSH helped make things better at the work place?	Yes No Nothing needed to change
If yes to Question 2, please describe the positive changes.
4. What is your overall impression of the NIOSH health hazard evaluation?	Excellent Good Fair Poor

NIOSH Health Hazard Evaluation Survey: One Year Later
Recommendations NIOSH made are printed in the left column below. First we ask about recommendations made to Managers, then about recommendations made to Employees. Please answer all of these questions. Please only mark one response for each question.
Recommendations to Managers	Was Action Taken?
5A.	Yes No O I don’t know O Not applicable now – the process ceased
5B.	Yes No O I don’t know O Not applicable now – the process ceased
5C.	Yes No O I don’t know O Not applicable now – the process ceased
5D.	Yes No O I don’t know O Not applicable now – the process ceased
5E.	Yes No O I don’t know O Not applicable now – the process ceased
5F.	Yes No O I don’t know O Not applicable now – the process ceased

NIOSH Health Hazard Evaluation Survey: One Year Later
Recommendations to Managers	Was Action Taken?
5G.	Yes No O I don’t know O Not applicable now – the process ceased
5H.	Yes No O I don’t know O Not applicable now – the process ceased
5I.	Yes No O I don’t know O Not applicable now – the process ceased
5J.	Yes No O I don’t know O Not applicable now – the process ceased
5K.	Yes No O Don’t know O Not applicable now – the process ceased
5L.	Yes No I don’t know Not applicable now – the process ceased
5M.	Yes No O I don’t know O Not applicable now – the process ceased

NIOSH Health Hazard Evaluation Survey: One Year Later
Recommendations to Managers	Was Action Taken?
5N.	Yes No O I don’t know O Not applicable now – the process ceased
5O.	Yes No O I don’t know O Not applicable now – the process ceased
5P.	Yes No O I don’t know O Not applicable now – the process ceased
5Q.	Yes No O I don’t know O Not applicable now – the process ceased
5R.	Yes No O I don’t know O Not applicable now – the process ceased
5S.	Yes No O I don’t know O Not applicable now – the process ceased
5T.	Yes No O I don’t know O Not applicable now – the process ceased

NIOSH Health Hazard Evaluation Survey: One Year Later
Recommendations to Employees	Was Action taken?
6A.	Yes No I don’t know O Not applicable now – the process ceased
6B.	Yes No I don’t know O Not applicable now – the process ceased
6C.	Yes No I don’t know O Not applicable now – the process ceased
6D.	Yes No I don’t know O Not applicable now – the process ceased
6E.	Yes No I don’t know O Not applicable now – the process ceased
6F.	Yes No I don’t know O Not applicable now – the process ceased

NIOSH Health Hazard Evaluation Survey: One Year Later
Recommendations to Employees	Was Action taken?
6G.	Yes No Don’t know O Not applicable now – the process ceased
6H.	Yes No Don’t know Not applicable now – the process ceased
6I.	Yes No Don’t know Not applicable now – the process ceased
6J.	Yes No Don’t know Not applicable now – the process ceased
6K.	Yes No Don’t know O Not applicable now – the process ceased
6L.	Yes No Don’t know O Not applicable now – the process ceased

NIOSH Health Hazard Evaluation Survey: One Year Later
7. Please provide details about actions taken or not taken regarding the NIOSH recommendations.
8. Please provide any comments you have about the NIOSH health hazard evaluation.
Are you still associated with the workplace that NIOSH evaluated?	Yes No
□ Administrative area □

Followback survey Form 3B