Health Hazard Evaluations/Technical Assistance and Emerging Problems

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0260 Specific Worker Questionnaire - example	Form and Instruction	Modified	Repair queued
Form 0920-0260 Att F_Sample HHE Specific Worker Questionnaire	Form and Instruction	Modified	Repair queued
Form 0920-0260 Sample Employee Contact Information Postcard	Form	Modified	Repair queued
Form 0920-0260 Att G_Sample Employee Contact Information Postcard	Form	Modified	Repair queued
Form 0920-0260 HHE Survey - FINAL Report	Form	Modified	Repair queued
Form 0920-0260 Att I_ HHE Survey - FINAL Report (with site visit)	Form	Modified	Repair queued
Form 0920-0260 HHE Followback Survey - FINAL Report - 1YR Later	Form	Modified	Repair queued
Form 0920-0260 Att J_HHE Followback Survey - FINAL Report - 1Yr Later	Form	Modified	Repair queued
Form 0920-0260 Followback without Onsite Evaluation - year 1	Form	Modified	Repair queued
Form 0920-0260 Att L_Followback Survey: One Year Later	Form	Modified	Repair queued
Form 0920-0260 Followback Survey (Closeout for HHE without site vite)	Form	Modified	Repair queued
Form 0920-0260 Att K_Followback Survey – Final Letter	Form	Modified	Repair queued
Form 0920-0260 Initial Site Visit Followback Survey Form	Form	Modified	Repair queued
Form 0920-0260 Att H_ Initial Site Visit Followback Survey Form	Form	Modified	Repair queued
Form 0920-0260 HHE Specific Worker Interview - example	Form	Modified	Repair queued
Form 0920-0260 Att D_Sample HHE Specific Worker Interview	Form	Modified	Repair queued
Form 0920-0260 HHE Request Form	Form	Modified	Repair queued
Form 0920-0260 Att C_Request for a Health Hazard Evaluation (Employees and Employers)	Form	Modified	Repair queued
Att E1._HRPP.pdf	Supplementary Document	Uploaded 2020-06-02	Repair queued
Att E_Consent Form.docx	Supplementary Document	Uploaded 2020-06-02	Repair queued
Att B_60dy200260.pdf	Supplementary Document	Uploaded 2020-06-02	Repair queued
Attachment A2.pdf	Supplementary Document	Uploaded 2017-08-31	Repair queued
Attachment A1.docx	Supplementary Document	Uploaded 2017-08-31	Repair queued
SSB.docx	Supporting Statement B	Uploaded 2020-06-02	Repair queued
SSA.docx	Supporting Statement A	Uploaded 2020-06-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
37747	Att F_Sample HHE Specific Worker Questionnaire	Form and Instruction	Modified	Specific Worker Questionnaire - example
37747	Att F_Sample HHE Specific Worker Questionnaire	Form and Instruction	Modified
212840	Att G_Sample Employee Contact Information Postcard	Form	Modified	Sample Employee Contact Information Postcard
212840	Att G_Sample Employee Contact Information Postcard	Form	Modified
185724	Att I_ HHE Survey - FINAL Report (with site visit)	Form	Modified	HHE Survey - FINAL Report
185724	Att I_ HHE Survey - FINAL Report (with site visit)	Form	Modified
185723	Att J_HHE Followback Survey - FINAL Report - 1Yr Later	Form	Modified	HHE Followback Survey - FINAL Report - 1YR Later
185723	Att J_HHE Followback Survey - FINAL Report - 1Yr Later	Form	Modified
185722	Att L_Followback Survey: One Year Later	Form	Modified	Followback without Onsite Evaluation - year 1
185722	Att L_Followback Survey: One Year Later	Form	Modified
185721	Att K_Followback Survey – Final Letter	Form	Modified	Followback Survey (Closeout for HHE without site vite)
185721	Att K_Followback Survey – Final Letter	Form	Modified
185720	Att H_ Initial Site Visit Followback Survey Form	Form	Modified	Initial Site Visit Followback Survey Form
185720	Att H_ Initial Site Visit Followback Survey Form	Form	Modified
185719	Att D_Sample HHE Specific Worker Interview	Form	Modified	HHE Specific Worker Interview - example
185719	Att D_Sample HHE Specific Worker Interview	Form	Modified
185718	Att C_Request for a Health Hazard Evaluation (Employees and Employers)	Form	Modified	HHE Request Form
185718	Att C_Request for a Health Hazard Evaluation (Employees and Employers)	Form	Modified

ICR Details

OMB Control No: 0920-0260	ICR Reference No: 202005-0920-003
Status: Historical Active	Previous ICR Reference No: 201708-0920-027
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0260
Title: Health Hazard Evaluations/Technical Assistance and Emerging Problems
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/11/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/03/2020
Terms of Clearance: Previous terms of clearance continue: approved for purposes of conducting investigations/evaluations, given the anecdotal nature of gathered data information obtained through these collections of information will not be used to develop estimates related to health or safety risks in general.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2024	36 Months From Approved	03/31/2021
Responses	5,653	0	9,648
Time Burden (Hours)	1,715	0	2,956
Cost Burden (Dollars)	58,545	0	100,982

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Abstract: PL 91-596 and PL 91-173 mandate that the National Institute for Occupational Safety and Health respond to requests for Health Hazard Evaluations (HHEs) to address chemical, biological, and/or physical workplace hazards. Responses require a valid written response; NIOSH receives about 300 requests per year. The diversity of requests precludes set questionnaires for the evaluations; a set of questionnaires for follow-back is used to assess HHE program effectiveness. Requests come from companies involving service, manufacturing, health and social services, transportation, construction, agriculture/mining, and skilled trades.

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Authorizing Statute(s): PL: Pub.L. 101 - 552 20 Name of Law: Occupational Safety and Health Act
   US Code: 42 USC 85 Name of Law: PHSA- Requests for HHE
   PL: Pub.L. 91 - 173 301 Name of Law: Federal Mine Safety and Health Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 7560	02/10/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 33679	06/02/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Att C_Request for a Health Hazard Evaluation (Employees and Employers)	0920-0260	HHE Request Form
Att D_Sample HHE Specific Worker Interview	0920-0260	HHE Specific Worker Interview - example
Att F_Sample HHE Specific Worker Questionnaire	0920-0260	Specific Worker Questionnaire - example
Att G_Sample Employee Contact Information Postcard	0920-0260	Sample Employee Contact Information Postcard
Att H_ Initial Site Visit Followback Survey Form	0920-0260	Initial Site Visit Followback Survey Form
Att I_ HHE Survey - FINAL Report (with site visit)	0920-0260	HHE Survey - FINAL Report
Att J_HHE Followback Survey - FINAL Report - 1Yr Later	0920-0260	HHE Followback Survey - FINAL Report - 1YR Later
Att K_Followback Survey – Final Letter	0920-0260	Followback Survey (Closeout for HHE without site vite)
Att L_Followback Survey: One Year Later	0920-0260	Followback without Onsite Evaluation - year 1

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	5,653	9,648	0	-3,995	0	0
Annual Time Burden (Hours)	1,715	2,956	0	-1,241	0	0
Annual Cost Burden (Dollars)	58,545	100,982	0	-42,437	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Forms

Short Statement: No new forms have been added to this request. The estimated total burden is reduced by 1244 hours. This reduction is accounted for by adjustments (decrease, as noted in recent trends) to the expected number of HHE requests and onsite evaluations, and therefore respondents.

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Annual Cost to Federal Government: $6,300,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/03/2020

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