[NIOSH] Health Hazard Evaluations/Technical Assistance and Emerging Problems

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0260 Request for a Health Hazard Evaluation - Spanish	Form and Instruction	Unchanged	Available
Form 0920-0260 Request for a Health Hazard Evaluation - English	Form and Instruction	Unchanged	Available
Form 0920-0260 Attachment K No Site Visit_ 1 Year After Final Letter Survey Form	Form	New	Available
Form 0920-0260 Attachment J No Site Visit_Followback Survey Form	Form	New	Available
Form 0920-0260 Followback Survey – One Year After Final Letter	Form and Instruction	Removed	Available
Form 0920-0260 Followback Survey – One Year After - Final Letter	Form and Instruction	Removed	Available
Form 0920-0260 Followback Survey – After HHE Final Letter	Form and Instruction	Removed	Available
Form 0920-0260 Followback Survey – One Year After the Final Report	Form and Instruction	Removed	Available
Form 0920-0260 Attachment I 1 Year Later After Final Report Followback Survey Form	Form	Modified	Available
Form 0920-0260 Attachment H After Final Report Followback Survey Form	Form	Modified	Available
Form 0920-0260 Attachment G Follwback Initial Site Visit Survey Form	Form	Modified	Available
Form 0920-0260 HHE Contact Postcard	Form and Instruction	Modified	Available
Form 0920-0260 HHE Specific Medical Survey Informed Consent Form	Form and Instruction	Modified	Available
Form 0920-0260 HHE Specific Questionnaire Example	Form and Instruction	Modified	Available
Form 0920-0260 HHE - Specific Interview Example	Form and Instruction	Modified	Available
Attachment E Informed Consent Example.docx	Supplementary Document	Uploaded 2026-10-20	Available
Attachment F Sample Employee Exposure Assessment Contact Information Postcard.docx	Supplementary Document	Uploaded 2026-10-20	Available
Attachment C Interview Example.docx	Supplementary Document	Uploaded 2026-10-20	Available
Attachment B2 HHERequest_Form_2023_Spanish.pdf	Supplementary Document	Uploaded 2026-10-20	Available
Attachment B1 HHERequest_Form_2023 English.pdf	Supplementary Document	Uploaded 2026-10-20	Available
Attachment F Sample Employee Exposure Assessment Contact Information Postcard.docx	Supplementary Document	Uploaded 2026-10-20	Available
Attachment L IRB Memorandum HHE Investigations are Not Research.pdf	Supplementary Document	Uploaded 2026-10-20	Available
Attachment A1 OSHAct and MSHA 1970.docx	Supplementary Document	Uploaded 2026-10-20	Available
PIA form.pdf	Supplementary Document	Uploaded 2023-11-27	Available
0920-0260_Supporting Statement B.docx	Supporting Statement B	Uploaded 2023-11-27	Available
0920-0260 Supporting Statement A 2026 Extension final_ EF 101926.docx	Supporting Statement A	Uploaded 2026-10-20	Available
Attachment A3 60dayFRN.pdf	Supplementary Document	Uploaded 2023-11-27	Available
Attachment A2.pdf	Supplementary Document	Uploaded 2017-08-31	Available
Attachment A1.docx	Supplementary Document	Uploaded 2017-08-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
37747	Employees/ employee representatives/ or employers - HHE Request Form	Form and Instruction	Unchanged	Request for a Health Hazard Evaluation - Spanish
37747	Employees/ employee representatives/ or employers - HHE Request Form	Form and Instruction	Unchanged	Request for a Health Hazard Evaluation - English
283151	Followback for Without Onsite Evaluations	Form	New	Attachment K No Site Visit_ 1 Year After Final Letter Survey Form
283151	Followback for Without Onsite Evaluations	Form	New	Attachment J No Site Visit_Followback Survey Form
263676	Employee Representative Closeout for HHE without Site Visit - Year 2	Form and Instruction	Removed	Followback Survey – One Year After Final Letter
212840	Employee Representative - Closeout for HHE without Site Visit - Year 1	Form and Instruction	Removed	Followback Survey – One Year After - Final Letter
185724	Employer and Employee Representative - HHE Followback Survey with Site Visit - Year 2	Form and Instruction	Removed	Followback Survey – After HHE Final Letter
185723	Employer and Employee Representative - Closeout HHE Followback Survey with Site Visit	Form and Instruction	Removed	Followback Survey – One Year After the Final Report
185722	Followback for Onsite Evaluations	Form	Modified	Attachment I 1 Year Later After Final Report Followback Survey Form
185722	Followback for Onsite Evaluations	Form	Modified	Attachment H After Final Report Followback Survey Form
185722	Followback for Onsite Evaluations	Form	Modified	Attachment G Follwback Initial Site Visit Survey Form
185721	Employees - Contact Postcard	Form and Instruction	Modified	HHE Contact Postcard
185720	Employee - HHE Specific Medical Survey Informed Consent	Form and Instruction	Modified	HHE Specific Medical Survey Informed Consent Form
185719	Employees - HHE Specific Questionnaire Example	Form and Instruction	Modified	HHE Specific Questionnaire Example
185718	Employees - HHE specific interview example	Form and Instruction	Modified	HHE - Specific Interview Example

ICR Details

OMB Control No: 0920-0260	ICR Reference No: 202610-0920-015
Status: Received in OIRA	Previous ICR Reference No: 202311-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-26-0227
Title: [NIOSH] Health Hazard Evaluations/Technical Assistance and Emerging Problems
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/21/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2027
Responses	5,713	7,043
Time Burden (Hours)	1,745	2,267
Cost Burden (Dollars)	0	0

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Abstract: PL 91-596 and PL 91-173 mandate that the National Institute for Occupational Safety and Health respond to requests for Health Hazard Evaluations (HHEs) to address chemical, biological, and/or physical workplace hazards. Responses require a valid written response; NIOSH receives about 300 requests per year. The diversity of requests precludes set questionnaires for the evaluations; a set of questionnaires for follow-back is used to assess HHE program effectiveness. Requests come from companies involving service, manufacturing, health and social services, transportation, construction, agriculture/mining, and skilled trades. This Revision ICR requests the following: 1) Addition of one new informed consent form; 2) Updating Spanish and English HHE Request Forms to add an additional 15 site visits; 3) Modification of FollowBack forms to reduce redundancy; and 4) Update the data collection in ROCIS to accurately reflect ongoing activities. Overall burden is increased by 552 hours.

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Authorizing Statute(s): US Code: 42 USC 85 Name of Law: PHSA- Requests for HHE
   PL: Pub.L. 91 - 173 301 Name of Law: Federal Mine Safety and Health Act
   PL: Pub.L. 101 - 552 20 Name of Law: Occupational Safety and Health Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 36834	06/18/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 65218	10/14/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Employee - HHE Specific Medical Survey Informed Consent	0920-0260	HHE Specific Medical Survey Informed Consent Form
Employee Representative - Closeout for HHE without Site Visit - Year 1	0920-0260	Followback Survey – One Year After - Final Letter
Employee Representative Closeout for HHE without Site Visit - Year 2	0920-0260	Followback Survey – One Year After Final Letter
Employees - Contact Postcard	0920-0260	HHE Contact Postcard
Employees - HHE Specific Questionnaire Example	0920-0260	HHE Specific Questionnaire Example
Employees - HHE specific interview example	0920-0260	HHE - Specific Interview Example
Employees/ employee representatives/ or employers - HHE Request Form	0920-0260, 0920-0260	Request for a Health Hazard Evaluation - English ,   Request for a Health Hazard Evaluation - Spanish
Employer and Employee Representative - Closeout HHE Followback Survey with Site Visit	0920-0260	Followback Survey – One Year After the Final Report
Employer and Employee Representative - HHE Followback Survey with Site Visit - Year 2	0920-0260	Followback Survey – After HHE Final Letter
Followback for Without Onsite Evaluations	0920-0260, 0920-0260	Attachment J No Site Visit_Followback Survey Form ,   Attachment K No Site Visit_ 1 Year After Final Letter Survey Form
Followback for Onsite Evaluations	0920-0260, 0920-0260, 0920-0260	Attachment G Follwback Initial Site Visit Survey Form ,   Attachment H After Final Report Followback Survey Form ,   Attachment I 1 Year Later After Final Report Followback Survey Form

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	5,713	7,043	0	-1,002	-328	0
Annual Time Burden (Hours)	1,745	2,267	0	-505	-17	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This is a request for an Extension of Health Hazard Evaluation/Technical Assistance and Emerging Problems requesting three years of approval and 1745 burden hours.

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Annual Cost to Federal Government: $5,313,105

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/21/2026

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