OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

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

OMB 0920-0260 · HHS/CDC.

OMB 0920-0260

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.

The latest form for [NIOSH] Health Hazard Evaluations/Technical Assistance and Emerging Problems expires 2027-01-31 and is listed under ICR 202311-0920-010.

View the official OMB control history on Reginfo.gov.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form 0920-0260 Request for a Health Hazard Evaluation - SpanishForm and Instruction
Form 0920-0260 Request for a Health Hazard Evaluation - EnglishForm and Instruction
Form 0920-0260 Attachment K No Site Visit_ 1 Year After Final Letter Survey FormForm
Form 0920-0260 Attachment J No Site Visit_Followback Survey FormForm
Form 0920-0260 Followback Survey – One Year After Final LetterForm and Instruction
Form 0920-0260 Followback Survey – One Year After - Final LetterForm and Instruction
Form 0920-0260 Followback Survey – After HHE Final LetterForm and Instruction
Form 0920-0260 Followback Survey – One Year After the Final ReportForm and Instruction
Form 0920-0260 Attachment I 1 Year Later After Final Report Followback Survey FormForm
Form 0920-0260 Attachment H After Final Report Followback Survey FormForm
Form 0920-0260 Attachment G Follwback Initial Site Visit Survey FormForm
Form 0920-0260 HHE Contact PostcardForm and Instruction
Form 0920-0260 HHE Specific Medical Survey Informed Consent FormForm and Instruction
Form 0920-0260 HHE Specific Questionnaire ExampleForm and Instruction
Form 0920-0260 HHE - Specific Interview ExampleForm and Instruction
Attachment E Informed Consent Example.docxSupplementary Document
Attachment F Sample Employee Exposure Assessment Contact Information Postcard.docxSupplementary Document
Attachment C Interview Example.docxSupplementary Document
Attachment B2 HHERequest_Form_2023_Spanish.pdfSupplementary Document
Attachment B1 HHERequest_Form_2023 English.pdfSupplementary Document
Attachment F Sample Employee Exposure Assessment Contact Information Postcard.docxSupplementary Document
Attachment L IRB Memorandum HHE Investigations are Not Research.pdfSupplementary Document
Attachment A1 OSHAct and MSHA 1970.docxSupplementary Document
PIA form.pdfSupplementary Document
0920-0260_Supporting Statement B.docxSupporting Statement B
0920-0260 Supporting Statement A 2026 Extension final_ EF 101926.docxSupporting Statement A
Attachment A3 60dayFRN.pdfSupplementary Document
Attachment A2.pdfSupplementary Document
Attachment A1.docxSupplementary Document
Employees/ employee representatives/ or employers - HHE Request Form Form and Instruction
Employees/ employee representatives/ or employers - HHE Request Form Form and Instruction
Followback for Without Onsite Evaluations Form
Followback for Without Onsite Evaluations Form
Employee Representative Closeout for HHE without Site Visit - Year 2 Form and Instruction
Employee Representative - Closeout for HHE without Site Visit - Year 1 Form and Instruction
Employer and Employee Representative - HHE Followback Survey with Site Visit - Year 2 Form and Instruction
Employer and Employee Representative - Closeout HHE Followback Survey with Site Visit Form and Instruction
Followback for Onsite Evaluations Form
Followback for Onsite Evaluations Form
Followback for Onsite Evaluations Form
Employees - Contact Postcard Form and Instruction
Employee - HHE Specific Medical Survey Informed Consent Form and Instruction
Employees - HHE Specific Questionnaire Example Form and Instruction
Employees - HHE specific interview example Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202610-0920-015 Extension without change of a currently approved collection 2026-10-21
202311-0920-010 Revision of a currently approved collection 2023-11-28 Approved without change
202005-0920-003 Revision of a currently approved collection 2020-06-03
201708-0920-027 Revision of a currently approved collection 2017-09-18 Approved without change
201408-0920-011 Revision of a currently approved collection 2014-09-09 Approved without change
201109-0920-006 Revision of a currently approved collection 2011-09-27 Approved without change
200807-0920-003 Reinstatement with change of a previously approved collection 2008-07-16 Approved without change
200504-0920-003 No material or nonsubstantive change to a currently approved collection 2005-04-29 Approved without change
200407-0920-004 Extension without change of a currently approved collection 2004-07-29 Approved without change
200104-0920-002 Extension without change of a currently approved collection 2001-04-02 Approved without change
199711-0920-003 Reinstatement without change of a previously approved collection 1997-11-24 Approved without change
199405-0920-003 Reinstatement with change of a previously approved collection 1994-05-16 Approved without change
199005-0920-007 New collection (Request for a new OMB Control Number) 1990-05-01 Approved without change

OMB Details

Employees/ employee representatives/ or employers - HHE Request Form

Federal Enterprise Architecture: Workforce Management - Worker Safety

Information collection instruments
FormNameElectronic accessType
Form 0920-0260Request for a Health Hazard Evaluation - EnglishN/AForm and instruction
Form 0920-0260Request for a Health Hazard Evaluation - SpanishN/AForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.