Occupational Safety and Health Program Evaluation Survey

Attachment H-2:

Occupational Safety and Health Program Evaluation Survey Year 2

Form Approved

OMB No. 0920-XXXX Exp.Date__xx/xx/20xx__

NOTE: All Year 2 respondents will answer the same Questions 1-65 from Year 1 (Attachment H-1).

If the Year 2 respondent is the same person as Year 1, the respondent will then answer questions A-D:

Question A: Do you have a new role in your company since you last completed this survey?

⃝ Yes

⃝ No  Skip to question C

Question B: What is your new role within your company? ________________

Question C: In the past 12 months has…

	Yes	No	Don’t know
…your workplace had a fatality?	⃝	⃝	⃝
…your workplace had a catastrophic injury which made return to work improbable for the injured employee?	⃝	⃝	⃝
…your workplace received a visit from an OSHA consultant?	⃝	⃝	⃝
…your workplace had a consultation with a BWC safety consultant?	⃝	⃝	⃝
…your workplace had a consultation with a BWC ergonomist?	⃝	⃝	⃝
…your workplace had a consultation with a BWC industrial hygienist?	⃝	⃝	⃝
…your workplace had a consultation with a private occupational safety & health consultant?	⃝	⃝	⃝
…personnel in your workplace participated in occupational safety & health initiatives through business associations?	⃝	⃝	⃝
…personnel in your workplace participated in other Occupational Safety and Health initiatives arising external to your workplace?	⃝	⃝	⃝
…your workplace conducted any wellness activities (i.e. fitness activities, smoking secession, health and fitness support)?	⃝	⃝	⃝
…your work place participated in the Ohio Bureau of Workers’ Compensation (BWC) Industry-Specific Safety Program?	⃝	⃝	⃝
	If Yes answer question below:
…your workplace participated in any of the other BWC Destination: Excellence Programs?	⃝	⃝	⃝

Public reporting burden for this collection of information is estimated to average 20 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 the burden estimate to CDC/ASTDR Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

Question D: Have any major changes occurred at your company in the past year that may have impacted Occupational Safety and Health? ___________________________________

If the Year 2 respondent is a different person from Year 1, the respondent will then answer questions C,D (above) and questions E-I:

E: What is your role within your company?

⃝ Owner/CEO/President/Senior Management (VP)

⃝ Manager

⃝ Supervisor

⃝ Lead Worker

⃝ Professional Staff

⃝ Skilled/Trades Staff

⃝ Administrative Staff

⃝ Worker

F: How long have you been working at your company?

⃝ Less than 1 year

⃝ 1 to 5 years

⃝ More than 5 years

G: Have you been working as a Health and Safety professional for your company?

⃝ Yes

⃝ No  Skip H

H: How long have you been working in a Health and Safety role for your company?

⃝ Less than 1 year

⃝ 1 to 5 years

⃝ More than 5 years

I: Are you…

⃝ Female?

⃝ Male?

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