Attachment K No Site Visit_ 1 Year After Final Letter Survey Form

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Followback Survey – One Year After the Final Letter
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 securely according to federal laws.  We will report only summary information and will not identify you.

Please fill in circles completely like this:
    1. 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.
    2. 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
    3. Did your company make (or intend to make) any specific changes based on the HHE findings or recommendations?
        ◦ Yes
        ◦ No
        ◦ Do not know
    4. How likely are you to seek safety and health information from NIOSH in the future?
        ◦ Very likely 
        ◦ Somewhat likely
        ◦ Somewhat unlikely
        ◦ Very unlikely
    5. Please explain why you will (or will not) seek safety and health information from NIOSH in the future.
    6. 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

    7. 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)




    8. Please explain why your company made or intends to make changes to improve safety and health as a result of the NIOSH evaluation.
    9. Please explain any challenges your company has experienced in implementing the NIOSH evaluation recommendations and why.
    10. If you have any ideas about how we can improve our services, please let us know here.


Followback Survey Form 3A										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.