Survey (Word)

Attachment G: HHE local health department survey, Data collection instrument

Form approved

OMB No. 0920-0879

Expiration date: 03/31/2014

Put intro here

Local Health Department Survey

1. What is your job title?

O Local health officer

O Other (please specify): ______________________________________________

2. Here are some ways in which health departments might provide assistance with occupational health issues. For each please tell us how often on average in the past year has your health department handled an occupational health issue in this way.

Never	Less than once per month	1 time per month	2-3 times per month	1-2 times per week	3 or more times per week
Visited the work place	O	O	O	O	O
Provided advice over the phone	O	O	O	O	O
Provided written information or guidance	O	O	O	O	O
Made a referral to another agency or organization	O	O	O	O	O

3. If you DID MAKE REFERRALS to other agencies/organizations, to which ones did you most frequently refer?

_____________________________________________________________________________

_____________________________________________________________________________

4. Here are some ways in which health departments might provide assistance with occupational health issues. For each please tell us how often on average in the past year has your health department handled an occupational health issue in this way.

	Strongly disagree	Disagree	Neither disagree nor agree	Agree	Strongly agree
Staff in my health department have expertise in occupational health issues	O	O	O	O	O
I am familiar with the programs and services of the National Institute for Occupational Safety and Health, or NIOSH?	O	O	O	O	O
I am familiar with the NIOSH Health Hazard Evaluation, or HHE, Program	O	O	O	O	O

5. If you are familiar with the HHE Program, what would you say were its main benefits?

6. In the past year, did you see an email from NIOSH telling you about a possible HHE?

O Yes

O No

0 Unsure

In the past year, did you see an email from NIOSH with a copy of its investigation report?

O Yes

O No

0 Unsure

7. How would you rate the value of getting this information? very useful/somewhat useful /not useful/don’t know/not applicable

8. Does your department want to:

1. get notices from the HHE Program about its work in your area? Yes/No/Unsure

2. get HHE reports from NIOSH for workplaces in your area? Yes/No/Unsure

9. If you do not want notices or reports or are unsure, please tell us a little about why.

10. Please tell us which of the following you have done. (Yes/No/Not Applicable)

1. contacted the HHE Program for assistance

2. referred others to the HHE Program

3. participated in an HHE with NIOSH

4. visited the HHE Program website

5. subscribed to Epi-X

6. selected Occupational Health as an area of interest in My Epi-X

13. If you have contacted the HHE Program for assistance, was your experience positive or not so positive? Tell us a little about your experience.

13. If you have visited the HHE Program website, did you find what you wanted? Yes/No/I did not visit the website

13. Please tell us how likely you are to do each of the following? (very likely/somewhat likely/somewhat unlikely/very unlikely)

    1. contact the HHE Program for assistance in the future

    2. participate (again) in an HHE if the opportunity arose

13. Share your thoughts about how the HHE Program can best help local health departments.

Thank you for taking the time to help the HHE Program.

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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).