Assessing Effectiveness Brochure: LHD/NHHE Progam Working Together AND STD Prevention Services

Appendix G. Word version of the data collection tool

Form approved

OMB No. 0920-0879

Expiration date 03/31/2014

The Health Hazard Evaluation Program of the National Institute for Occupational Safety and Health invites you to participate in the assessment of our new brochure. This data collection instrument is designed to gather information from local health officials related to the services of the Health Hazard Evaluation Program. No personally identifiable information is requested and your responses will be anonymous. If you have questions or concerns about this activity, please contact Allison Tepper at 513.841.4488 or [email protected].

For which of the following issues affecting a workplace would you think of using the Health Hazard Evaluation Program? Check all that apply.

O Pesticide exposure	O Heat stress	O Job stress
O Mold on ceiling tiles	O Confined spaces	O Breathing problems
O Electrical hazards	O Heavy lifting	O Cancer cluster
O Repetitive motions	O Noise exposure	O Kidney disease
O Tuberculosis	O Shift work	O Zoonoses
O Slips, trips, and falls	O Influenza	O Lead exposure
0 Transportation accidents	O Indoor air quality	O Electromagnetic fields
O Carpal tunnel syndrome	O Amputations	O Neuropathies

Check whether the following statements about the HHE Program are true or false.

	True	False
The HHE Program has authority to investigate state and local agencies.
The HHE Program always has authority to investigate a workplace when asked to do so by a local health official.
The HHE Program shares its reports with the Occupational Safety and Health Administration.
New reports on the HHE Program website do not include the name of the workplace that was investigated.
NIOSH must tell an employer the name of the employees who submit HHE requests.
The HHE Program can issue a citation if an employer does not follow its recommendations.
The HHE Program has the ability to interact with employers and employees who do not speak English.
The HHE program will likely do a field investigation when the request concerns mold in a school or office building.

In discussing the HHE Program with people in your community, which of the following would you choose to mention? Select the three items you think are most important.

O	Expertise of investigators
O	Reputation of CDC
O	No cost to requestors
O	Timing of response
O	Objectivity of investigators
O	Public availability of reports
O	Non-enforcement nature of HHE recommendations

Before getting this brochure, how familiar were you with the HHE Program?

0	Not at all familiar
0	Somewhat familiar
0	Very familiar

After reading this brochure, how likely are you to contact the HHE Program?

O	Very unlikely
O	Somewhat unlikely
O	Somewhat likely
O	Very likely
O	Not sure

Regarding your likelihood of contacting the HHE Program now, is it more than in the past, about the same as in the past, or less than in the past?

O	More now than in the past
O	About the same now as in the past
O	Less now than in the past

After reading this brochure, how likely are you to refer someone to the HHE Program if the situation warranted it?

O	Very unlikely
O	Somewhat unlikely
O	Somewhat likely
O	Very likely
O	Not sure

Regarding your likelihood of referring someone to the HHE Program now, is it more than in the past, about the same as in the past, or less than in the past?

O	More now than in the past
O	About the same now as in the past
O	Less now than in the past

How relevant are the HHE Program’s services to your work?

O	Not at all relevant
O	Mostly not relevant
O	Somewhat relevant
O	Very relevant
O	Not sure

Do you know what to do if you have a question about the HHE Program?

O	No
O	Yes

How satisfied are you with each of the following features of the brochure?

	Very satisfied	Somewhat Satisfied	Not satisfied
Content	O	O	O
Organization	O	O	O
Graphics	O	O	O
Length	O	O	O

Would it be helpful to get paper copies of the brochure to share with your staff?

O	No
O	Yes

Do you have unanswered questions about the HHE Program?

O	No
O	Yes

If “Yes,” list the two of most concern to you.

Thank you for your responses.

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reading the brochure, reviewing instructions, and completing the web-based survey. 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 (0920-0879).