0920-0260 Request for a Health Hazard Evaluation - English

Request for a Health Hazard Evaluation
This form also is available at https://www.cdc.gov/niosh/hhe/request.html

Form Approved
OMB No. 0920-0260
Exp. 03/31/2024

Workplace Name______________________________________________________________________________
Workplace Address ____________________________________________________________________________

State
Street
City
Zip Code

What type of work is done at this location? ________________________________________________________
How many people work at this location?

O 3 or less
O 4-9
O 10-49
O 50-99
O 100-249
O 250 or more
Who is responsible for employee health and safety in this workplace?

Name_________________________ Title___________________________ Phone number________________
What hazardous substances, agents, or work conditions are of concern? If known, please include chemical names, trade
names, manufacturer name, or other identifying information.

What health concerns do people in this work area have?

In what work area, such as a building or department, is the hazard? _______________________________________
How many people work in this area?
O 3 or less O 4-9

O 10-49

O 50-99

O 100-249

O 250 or more

Describe the work people do in this area.

Complete this section if you are an employee submitting a request
(See page 2 if you are a union or employer representative)
Name (please print):_______________________________________________
Address where we can send you information? ______________________________________________________
Street
City
State
Zip Code
Phone number where you would like to be called: (_____) __________________
Best time to call: _________________
a.m. or
p.m.
Email address where you would like to be contacted: ________________________________________________
Can NIOSH reveal your name to your employer?
No
Yes
Please check one:
I am a current employee and 3 or fewer employees are exposed to the hazard.
O I am a current employee and more than 3 employees are exposed to the hazard.
If you check this box, two other employees need to sign this form and provide their contact information.
Public reporting burden of this collection of information is estimated to average 12 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).

Second employee
Name (Please print): _______________________________________________
Address where we can send you information? ______________________________________________________
Street
City
State
Zip Code
Phone number where you would like to be called: (_____) __________________
Best time to call: _________________
a.m. or
p.m.
Email address where you would like to be contacted: _________________________________________________
O No
O Yes
Can NIOSH reveal your name to your employer?

Third Employee
Name (Please print): _______________________________________________
Address where we can send you information? ______________________________________________________
Street
City
State
Zip Code
Phone number where you would like to be called: (_____) __________________
Best time to call: _________________
a.m. or
p.m.
Email address where you would like to be contacted: _________________________________________________
O Yes
Can NIOSH reveal your name to your employer?
No

Complete this section if you are a union representative
Name of union: ______________________________________________________________________________

Address: ___________________________________________________________________________________

Street
City
State
Zip Code

What is your position in the union? ______________________________________________________________

Complete this section if you are an employer representative

Name: _____________________________________________________________________________________

What is your position in the company, agency, or organization? _______________________________________

For everyone

O No
O Yes
O Do not know
Has another government agency evaluated this workplace?
If yes:
What agency? _________________________________________________________________________
What year was the evaluation done? _______________________________________________________
O Check here if this evaluation is underway now
Is a request for the hazard being filed with another agency?
O No
O Yes
O Do not know

If yes:

What agency? _________________________________________________________________________
How did you learn about the NIOSH Health Hazard Evaluation Program?
O NIOSH website
O Facebook
O Other website (Explain :______________________________________)
O CDC 1-800 number O Union
O Coworkers O Company official
O Trade/industry/union magazine or newsletter
O Other (Explain :________________________________)
To

submit this form by email, save the completed form to your computer and send it as an email attachment to
[email protected].
To submit this form by fax, send it to (513) 841-4488.

To submit this form by mail, send it to: National Institute for Occupational Safety and Health

1090 Tusculum Ave, MS R-9
Cincinnati, Ohio 45226-1998
Thank you for submitting this form. You will get a response from us within 10 days.