Local HD Survey

Form Approved

OMB No.0920-0940

Expires 03/31/2018

Local Health Department Survey: FY2017

Recognition/Recall of HHE Program and Brochure

1. How familiar are you with the National Institute for Occupational Safety and Health (NIOSH)?

1 – Not at all familiar

2 – Slightly familiar

3 – Somewhat familiar

4 – Moderately familiar

5 – Extremely familiar

2. How familiar are you with the NIOSH Health Hazard Evaluation (HHE) Program?

1 – Not at all familiar

2 – Slightly familiar

3 – Somewhat familiar

4 – Moderately familiar

5 – Extremely familiar

3. Did you receive a copy of the “Local Health Departments and the NIOSH Health Hazard Evaluation Program: Working Together” brochure? (Provide image of report cover in survey)

1. Yes

2. No

4. If yes, how did you receive the brochure?

1. I received a paper copy in the mail.

2. I received a digital copy via email.

3. I did not receive a copy/I’m not sure. (Provide link to website version and thank them for participating.)

4. Other:

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 D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0940).

5. Did you read the brochure?

1. Yes

2. No (“Please read the brochure before answering the following questions. You can access the web version of the brochure here.” Provide link to website version.)

Knowledge about HHE Program and Services- Comprehension of Brochure Material

Please check whether the following statements about the HHE Program are true or false. (questions from previous survey)

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

Attitudes/Intentions

Please rate your agreement with the following statements on a scale from 1- strongly disagree to 7- strongly agree.

Level of Agreement

1. 1 – Strongly disagree

2. 2 – Disagree

3. 3 – Somewhat disagree

4. 4 – Neither agree or disagree

5. 5 – Somewhat agree

6. 6 – Agree

7. 7 – Strongly agree

15. The HHE Program provides services that are relevant to my work.

16. The HHE Program is a credible source for occupational health and safety information.

17. The HHE Program has experts from a range of disciplines.

18. The HHE Program can investigate a variety of hazards in the workplace.

19. The HHE Program is a valuable resource for local health departments.

20. I would read HHE reports about evaluations in my jurisdiction.

21. I plan to share information about the HHE Program with my colleagues.

22. I would contact the HHE program if I needed assistance with an occupational health issue.

23. I would refer someone to the HHE Program if the situation warranted it.

24. I plan to search for HHE reports that are relevant to my work in the future.

Future Channel Preferences

25. Would you be interested in receiving more information from the HHE Program?

1. Yes

2. No

26. If yes, how do you prefer to receive that information?

1. Mail

2. Email

3. Other:

27. Please list, if any, other resources you would be interested in receiving and how often you wish to receive them.

28. After reading the brochure, did you have any unanswered questions? If yes, please list them here.