Attachment H After Final Report Followback Survey Form

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Followback Survey – After the Health Hazard Evaluation Final Report
NIOSH wants to know what you think about the recently completed health hazard evaluation at [workplace name]. 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?   
        ◦ Excellent
        ◦ Good 
        ◦ Fair 
        ◦ Poor
    2. What, if anything, would have made it better?
    3. Have any changes been made at the workplace based on the NIOSH recommendations?
        ◦ Yes
        ◦ No
        ◦ I don’t know
    4. Do you think NIOSH helped make things better at the workplace?  
        ◦ Yes 
        ◦ No 
        ◦ No changes were needed
    5. If “Yes” to Question 2, please describe the positive changes.  

    6. Which best describes what you think NIOSH found?
        ◦ NIOSH found a health hazard
        ◦ NIOSH did not find a health hazard
        ◦ NIOSH did not decide whether there was a health hazard
        ◦ NIOSH findings were not clear to me
        ◦ I don’t know
    7. Did the employer post the final report so employees could see it?  
        ◦ Yes
        ◦ No
        ◦ I don’t know
For Questions 8-19, please rate your agreement with the following statements.

Strongly Agree
Mostly Agree
Neither Agree/
Disagree
Mostly Disagree
Strongly Disagree
    8. The report was helpful.
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    9. I easily found the information I needed in the report. 
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    10. The Main Report contained all the information I needed.


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    11. The Supporting Technical Sections were useful to me. 
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    12. I trust the information in the report.  
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    13. I understood the key findings in the Main Report.
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    14. I understood the report’s recommendations.   
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    15. I agree with the report’s key findings.  
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    16. After reading the report, I was convinced that my workplace should follow the recommendations.
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    17. I found the graphs helpful in understanding the findings. (Skip this question if your report did not contain graphs).
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    18. The look of the report made it easy to read.
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    19. Did NIOSH issue the final report in a reasonable amount of time?
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    20. If you specifically liked something about the evaluation or have ideas about what NIOSH could do differently, let us know here.
    21. Did the NIOSH response change your thinking about the workplace concerns? 
        ◦ Yes
        ◦ No
    22. Overall, do you think the NIOSH recommendations address the workplace concerns well?
        ◦ Yes
        ◦   No
        ◦ I don’t know
    23. Overall, do you think the NIOSH recommendations are practical?
        ◦ Yes
        ◦ No
        ◦ I don’t know
    24. Are you still associated with the workplace that NIOSH evaluated?
        ◦ Yes 
        ◦ No  


Followback Survey Form 2B										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.