Form 0920-0260 Followback Survey – One Year After the Final Report

Form Approved OMB No.: 0920-0260

Expiration Date: xx/xx/20xx

Followback Survey – One Year After the Final Report

NIOSH wants to learn about your workplace now and actions taken regarding our recommendations from the health hazard evaluation at [workplace name]. 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:
How helpful was the NIOSH evaluation in reducing hazards and preventing work-related illness at [workplace name]?	Extremely helpful Very helpful Moderately helpful Slightly helpful Not at all helpful
Please explain your answer about how NIOSH helped or did not help make things better.
Please rate your agreement with the following statement: The main issue(s) that were the focus of the NIOSH evaluation have been resolved.	Strongly agree Mostly agree Neither agree nor disagree Mostly disagree Strongly disagree
Did your company make (or intend to make) any specific changes based on the HHE findings or recommendations?	Yes No Do not know
How likely are you to seek safety and health information from NIOSH in the future?	Very likely Somewhat likely Somewhat unlikely Very unlikely
Please explain why you will (or will not) seek safety and health information from NIOSH in the future.
If you would like more information from NIOSH, please indicate your top three sources.	HHE report Conference presentation or meeting NIOSH website NIOSH eNews, newsletters, social media, or science blogs NIOSH article published in an academic journal NIOSH article published in a trade magazine I do not want to get more information from NIOSH

Our evaluation report provided findings and recommendations for your workplace. Please indicate which of these specific changes were made at your company or that your company intends to implement within the near future.
NIOSH finding or recommendation	My company made this change.	My company plans to make this change in the near future.	I’m unsure if this change was or will be made.	My company has no plans to make this change.
Add example specific to study population
Add example specific to study population
Add example specific to study population
Add example specific to study population
Other changes (please specify)
Please explain why your company made or intends to make changes to improve safety and health as a result of the NIOSH evaluation.
Please explain any challenges your company has experienced in implementing the NIOSH evaluation recommendations and why.
If you have any ideas about how we can improve our services, please let us know here.

Public reporting burden of this collection of information is estimated to average 20 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 3B 12/12/2023

Thank you for completing this survey!

Call the Followback Coordinator at 513-841-4382 if you have questions or comments.