Form 0920-0260 Followback Survey (Closeout for HHE without site vite)

Form Approved
OMB No.: 0920-0260
Expiration Date:

Followback Survey – Final Letter
The National Institute for Occupational Safety and Health (NIOSH) surveys people involved with its health
hazard evaluations. We want to learn your thoughts about the evaluation NIOSH recently completed.
Your responses will be kept securely according to federal laws. Our reports include only summary
information and will not identify you. If NIOSH made specific workplace recommendations, we will send you
one more survey, in about one year.
Thank you for completing this survey.
Please fill in circles completely like this:
1. Did NIOSH issue the final letter in a reasonable time after you
requested the health hazard evaluation?

O Yes
O No

2. Is the final letter helpful?

O
O
O
O
O

Yes, very helpful
Yes, somewhat helpful
No, not very helpful
No, not at all helpful
I didn’t read it

O
O
O
O
O
O
O
O

Yes
No
Recommendations were not made
I don’t know
Yes
No
Recommendations were not made
I don’t know

3. Do the NIOSH recommendations address the workplace concerns
well?

4. Overall, do you think the NIOSH recommendations are practical?

5. Did the employer post the final letter at the workplace?

O Yes
O No
O Not applicable - NIOSH did not send
the final letter to the employer

6. Did you share the final letter with others at the workplace?

O Yes
O No

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 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 Information Collection Review Office, 1600 Clifton Road
NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0260).

7. If NIOSH suggested contacting another agency or organization for
assistance, did you or anyone else do this?

O
O
O
O

8. Did the NIOSH response change your thinking about your workplace
concerns?

O Yes
O No

Yes
No
I don’t know
No such suggestion was made

9. Please explain your answer.

10. What do you think about the health hazard evaluation?

O
O
O
O

It was Excellent
It was Good
It was Fair
It was Poor

11. Please tell us more of your thoughts about the health hazard evaluation.

12. If you were concerned about a possible workplace health hazard,
would you request another health hazard evaluation?

O Yes
O No

13. Are you still associated with the workplace that NIOSH evaluated?

O Yes
O No

Please make any corrections to this label

6/25/2014
Please mail the completed survey to NIOSH in the enclosed postage paid envelope.
Call Barbara Jenkins at 513-458-7132 if you have any questions about this survey.

Followback Survey Form 2A – 33825