Attachment G Follwback Initial Site Visit Survey Form

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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 securely according to federal laws.  We will report only summary information and will not identify you.

Please fill in circles completely like this:
    1. What do you think about the NIOSH health hazard evaluation?
        ◦ It is Excellent
        ◦ It is Good
        ◦ It is Fair
        ◦ It is Poor
    2. 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
    3. If you were not very satisfied with the communications, what could NIOSH do to make them better?
    4.  Was the letter NIOSH sent you after the site visit helpful?
        ◦ Yes, very
        ◦ Yes, somewhat
        ◦ Mostly not
        ◦ Not at all
    5. Do you think that NIOSH has been objective?
        ◦ Yes
        ◦ No
    6. We’d like to know more. What did we get right? What could we have done better?


    7. If you have any suggestions for us as we move forward with our evaluation at [workplace name], let us know.

    8. Are you still associated with the workplace that NIOSH is evaluating?
        ◦ Yes
        ◦ No

Followback Survey Form 1A										10/22/2026
Thank you for completing this survey!
Call the Followback Coordinator at 513-841-4382 if you have questions or comments. 
We may contact you again at the end of the evaluation.

Privacy Act Statement
The National Institute for Occupational Safety and Health (NIOSH) Health Hazard Evaluation (HHE) Program collects this information under Section 20 of the Occupational Safety and Health Act (29 U.S.C. § 669). Collection of the last four digits of your Social Security Number is authorized pursuant to Executive Order 9397, as amended. NIOSH will use the information you provide to conduct Health Hazard Evaluations, maintain accurate participant records, perform follow-up activities when necessary, and distinguish among individuals with similar names to ensure accurate record matching and management. Providing this information is voluntary; however, failure to provide requested identifying information, including the last four digits of your Social Security Number, may limit NIOSH's ability to accurately maintain records or conduct follow-up activities.

The Privacy Act of 1974 (5 U.S.C. § 552a) governs the collection and use of this information. Records are maintained in CDC/NIOSH System of Records Notice (SORN) 09-20-0147, Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records. Information may be disclosed outside CDC only as permitted by the Privacy Act, in accordance with the routine uses published for this system of records, and as otherwise authorized by law. Records will be maintained and protected in accordance with applicable federal privacy and security requirements.