Worker Notification Feedback Survey

Attachment A

Form Approved

OMB No. 0920-0953

Exp. Date 7/31/2018

Please let us know what you think about [X]. Do not provide your name or other information that would identify you such as your address or telephone number.

1. Please check all that apply:

• I received a letter from NIOSH because I am a current [or former, if appropriate] worker in a NIOSH study.

• I received a letter from NIOSH because I am a family member of a worker in a NIOSH study.

• I did not receive a letter from NIOSH, but I know someone who did.

• I received a letter from NIOSH, but I am not sure why.

• I found [X] by searching the internet (e.g., Google).

Comments:

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2. Does the information we provide in [X] meet your needs?

   • Yes

   • Not sure

   • No

Comments:
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3. Do you think that we understand the issues that are important to workers?

   • Yes

   • Not sure

   • No

Comments:
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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 D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0953).

4. Do you think that we have workers’ best interest in mind?

   • Yes

   • Not sure

   • No

Comments:
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5. Do you think that we have the knowledge needed to evaluate health and safety in your workplace?

   • Yes

   • Not sure

   • No

Comments:
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6. Do you think that [X] provides helpful recommendations?

   • Yes

   • Not sure

   • No

Comments:
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7. Do you trust the information presented in [X]?

   • Yes

   • Not sure

   • No

Comments:
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8. Please check all that apply:

   • I use the internet look for health information.

   • I get health information from printed sources such as books, magazines, and pamphlets.

   • I prefer to have printed copies of health information mailed to me.

   • I looked up further information on [X] using the links provided [in/on X].

   • I plan on contacting NIOSH at the email address or telephone number provided [in/on X].

   • I plan on requesting printed copies of [X].

   • I plan on sharing [X] with my doctor.

Comments:

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9. Please share any other comments you have. ______________________________________________________________________________________

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Thank you for taking the time to complete our survey. Your feedback will help us improve how we communicate our research. If you have questions, or would like to request printed copies of [X], please send an email to [email protected], or call (513) 458-7118.