Form 0920-0260 Followback Survey – After HHE Site Visit

F orm Approved OMB No.: 0920-0260

Expiration Date: xx/xx/20xx

Followback Survey – After the Health Hazard Evaluation Site Visit

NIOSH wants to know what you think about the health hazard evaluation at [workplace name] so far. Your feedback will help us create a better experience for you and others. We will keep your information secure according to federal laws. We will report only summary information and will not identify you.

Please fill in circles completely like this:
What do you think about the NIOSH health hazard evaluation?		It is Excellent It is Good It is Fair It is Poor
How satisfied were you with the communications by the NIOSH investigators about their plans and activities?		Very satisfied Mostly satisfied Neither satisfied nor dissatisfied Mostly dissatisfied Very dissatisfied
If you were not very satisfied with the communications, what could NIOSH do to make them better?
Was the letter NIOSH sent you after the site visit helpful?		Yes, very Yes, somewhat Mostly not Not at all
Do you think that NIOSH has been objective?		Yes No
We’d like to know more. What did we get right? What could we have done better?
If you have any suggestions for us as we move forward with our evaluation at [workplace name], let us know.
Are you still associated with the workplace that NIOSH is evaluating?	Yes 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 H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-0260).

Followback Survey Form 1A 12/12/2023

Thank you for completing this survey!

C all the Followback Coordinator at 513-841-4382 if you have questions or comments.
We may contact you again at the end of the evaluation.