OSHA-Participation in National Fall Prevention Safety Stand Down (NFPSSD) Feedback Survey

Thank you for participating in the 2015 construction fall prevention Stand-Down. I would like to
present your business with a certificate recognizing your commitment to workplace safety
through your participation in this event. Raising awareness of fall hazards and how to prevent
them is an important step in protecting workers. Please build on this step. Keep looking for fall
hazards and take preventive measures to save lives.
Sincerely,
Thomas E. Perez

Secretary of Labor

To print a certificate for your business's participation in the Stand-Down, please fill out the information below. Once you submit this information, you
will receive a certificate with your business name (a printable PDF document will appear). We also hope that you will help us by answering a few
optional questions about your Safety Stand-Down and giving us feedback on our campaign. Please note that you are not required to request a
certificate and that if you choose to do so OSHA will not use the information or feedback you provide for any purpose other than evaluating the StandDown campaign and planning future outreach efforts. Also note that the certificate does not represent an assessment of compliance with OSHA
standards at your worksite(s).

Items marked * are mandatory to print the certificate.
1. Name of Business*:
2. State*:
3.

Type of Industry*:

Select One
Select One

4. Number of Workers who participated*:

[Commercial Construction, Residential Construction, Highway, Other Construction, Non Construction, Government]

(Numbers only field)

5. Please tell us about your Stand-Down. What did you do? What materials did you use? How did it go? What do you expect to happen as a result of the
Stand-Down? (Optional. Limit entry to 4000 characters.)
Limit entry to 4000 characters.

6. How can we improve future initiatives like this? What could have been better? (Optional. Limit entry to 4000 characters.)
Limit entry to 4000 characters.

OMB Control Number xxxx-xxxx
Expiration date: 06/30/2015
PAPERWORK REDUCTION ACT
Public reporting burden for this voluntary collection of information is estimated to average 10 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
OSHA will use this information to evaluate the National Fall Prevention Safety Stand-Down. Persons are not required to respond to the collection of
information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data
collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Directorate of Standards and Guidance N-3609, 200
Constitution Avenue, NW, Washington, DC 20210.