Form OSHA 12-10.8 OSHA 12-10.8 Alliance Feedback Questionnaire

OMB No. 1218-XXXX

Exp. Date: xx/xx/2022

[Insert Name] Alliance Feedback Questionnaire

Instructions:

The purpose of this questionnaire is to gather your perceptions and comments on the [Insert Name] Alliance. This information will be used by the Occupational Safety and Health Administration (OSHA) and [Insert Alliance Program partner name] to enhance the Alliance and better direct our collaborative efforts. Please provide your rating in response to each questions and provide any additional comments in the space provided. We appreciate your time and effort in completing this questionnaire.

Questionnaire:

1. What is your perception of the impact of the Alliance on workplace safety and health in your industry? Please provide any additional comments or suggestions.

No Knowledge of the Alliance

1 2 3 4 5

Comments:

(Highly Favorable) (Highly Unfavorable)

2. Has the dissemination of safety and health information, products, and training (e.g., webinars, presentations at meetings, etc.) done through the Alliance been effective in raising awareness of workplace safety and health hazard in your industry? Please provide any additional comments or suggestions.

No Knowledge of the Alliance

1 2 3 4 5

Comments:

(Highly Effective) (Not Effective)

OSHA 12-10.8

3. Have the safety and health information, products, and training (e.g., webinars, presentations at meetings, etc.) disseminated by the Alliance reached and been used by employers and workers in the industry? Please provide any additional comments or examples.

No Knowledge of the Alliance

1 2 3 4 5

Comments:

(Highly Likely) (Highly Unlikely)

4. Have the products and training developed and distributed through the Alliance been effective for their intended audience? Please provide any additional comments or suggestions.

No Knowledge of the Alliance

1 2 3 4 5

Comments:

(Highly Effective) (Not Effective)

5. Have positive changes been made to improve workplace safety and health as a result of the safety and health information, products, and training (e.g., webinars, presentations at meetings, etc.) disseminated through the Alliance? Please provide any additional comments or examples.

No Knowledge of the Alliance

1 2 3 4 5

Comments:

(Changes Highly) (No Changes Made)

Likely

PAPERWORK REDUCTION ACT STATEMENT

OSHA’s Alliance Program distributes the Alliance feedback questionnaire to gather information about the value and impact of an Alliance’s activities, including the dissemination and use of information, products, and training developed and shared by the Alliance. Under the Paperwork Reduction Act, a Federal agency generally cannot conduct or sponsor, and the public is generally not required to respond to, an information collection, unless it is approved by OMB and displays a valid OMB Control Number. Use of this template is voluntary. The template ensures that national Alliance participants provide required information about Alliance activities to OSHA. OSHA estimates employer burden for the completion of this collection of information ranges from 1 to 8 hours, with an average of 1.5 hours. This estimate includes the time for reviewing instructions, assembling data and information, and responding to the questions. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to [email protected] or to OSHA’s Directorate of Cooperative and State Programs, Office of Outreach Services and Alliances, Department of Labor, Room N-3662, 200 Constitution Ave., NW, Washington, DC 20210; Attn: Paperwork Reduction Act Comment. 1218 –XXXX (This address is for comments regarding this form only; DO NOT SEND ANY COMPLETED TEMPLATES TO THIS OFFICE IN THIS MANNER.)

OMB Approval # 1218-xxxx; Expires: 00-00-0000