Form 0920-0260 Followback without Onsite Evaluation - year 1

NIOSH Health Hazard Evaluation Survey: One Year Later

NIOSH Health Hazard Evaluation Survey: One Year Later
The recommendations that NIOSH made are in the left column below.
Please mark one response for each item.

This survey asks what has happened at the work place in the year since NIOSH completed
the health hazard evaluation. Please fill in circles completely like this:

Recommendation
1. Do you think NIOSH helped make things better at
the work place?

O Yes
O No
O Nothing needed to change

8A.

O
O
O
O

Yes
No
I don’t know
No longer applies

8B.

O
O
O
O

Yes
No
I don’t know
No longer applies

8C.

O
O
O
O

Yes
No
I don’t know
No longer applies

8D.

O
O
O
O

Yes
No
I don’t know
No longer applies

8E.

O
O
O
O

Yes
No
I don’t know
No longer applies

8F.

O
O
O
O

Yes
No
I don’t know
No longer applies

8G.

O
O
O
O

Yes
No
I don’t know
No longer applies

2. If yes to Question 2, please describe the positive changes.

3. Do you still use, refer, to or discuss the NIOSH
letter?

O Yes
O No

4. Did the NIOSH evaluation change your behaviors
about workplace health and safety?

O Yes
O No

5. If yes, please explain.

6. Did the NIOSH evaluation change your thinking
overall about workplace health and safety?

O Yes
O No

Was Action Taken?

7. If yes, please explain.

NIOSH Health Hazard Evaluation Survey: One Year Later
Recommendation

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

Was Action Taken?

8H.

O
O
O
O

Yes
No
I don’t know
No longer applies

8I.

O
O
O
O

Yes
No
I don’t know
No longer applies

8J.

8K.

O
O
O
O

Yes
No
I don’t know
No longer applies

O
O
O
O

Yes
No
I don’t know
No longer applies

9. Please provide details about actions taken and not taken regarding the NIOSH recommendations.

Followback Survey
Final Letter ‒ One Year Later
The National Institute for Occupational Safety and Health (NIOSH) surveys people
involved with its health hazard evaluations. We want to learn about your workplace
now and actions taken regarding our recommendations.
Your responses will be kept securely according to federal laws. Our reports
include only summary information and will not identify you.
Thank you for completing this survey.

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 the survey

6/25/2014

Administrative area
Followback Survey Form 3A
14722

Public reporting burden of this collection of information is estimated to average 15 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN: PRA (0920-0260).