0920-1154 Employee Survey

Form Approved

OMB No. 0920-1154

Exp. Date XX/XX/20XX

Employee Survey

The purpose of this survey is to evaluate this training program. Your feedback is very important to help us improve this training.

Please provide the one best answer for each question.

Have you participated in training about heat stress in the past 2 years?  No  Yes  Unsure

To what extent do you agree with the following statements?	Disagree strongly	Disagree somewhat	Disagree slightly	Neither agree or disagree	Agree slightly	Agree somewhat	Agree strongly
	1	2	3	4	5	6	7
This training was valuable.							
I learned something new from this training.							
The case examples made the messages about heat illness easier to understand.							
I am more aware of things that may increase my risk for heat illness.							
I am more likely to change what I am doing to reduce my risk of heat illness (e.g., wear different clothing, take more breaks, drink more fluids).							
I can recognize signs of heat stress for myself.							
I am confident I can recognize when a colleague may be in trouble from the heat.							
I know how to help a colleague experiencing possible heat illness.							

Please give us written feedback to these questions. Your detailed feedback will provide more information to make improvements.

What was the most helpful thing about this training?

How can we improve this training?

What else can your employer do to help protect you from heat illness?

We will provide a brief one-page summary of findings from this survey. If you are interested, please contact your Occupational Safety and Health manager for results within three months. You may also contact Kristin Yeoman of NIOSH at [email protected].

Public reporting burden of this collection of information is estimated to average 5 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 Reports Clearance Officer; 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-1154).