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

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. CDC requests minor revisions to data collection forms and burden reduction based on past experience.

The latest form for [NIOSH] Health Hazard Evaluations/Technical Assistance and Emerging Problems expires 2021-01-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 0920-0260 Employees/ employee representatives/ or employers - HHE Request Form Form and Instruction
Form 0920-0260 Employee Representative Closeout for HHE without Site Visit - Year 2 Form and Instruction
Form 0920-0260 Employee Representative - Closeout for HHE without Site Visit - Year 1 Form and Instruction
Form 0920-0260 Employer and Employee Representative - HHE Followback Survey with Site Visit - Year 2 Form and Instruction
Form 0920-0260 Employer and Employee Representative - Closeout HHE Followback Survey with Site Visit Form and Instruction
Form 0920-0260 Employer and Employee Representative - Followback for Onsite Evaluations – Year 1 Form and Instruction
Form 0920-0260 Employees - Contact Postcard Form and Instruction
Form 0920-0260 Employee - HHE Specific Medical Survey Informed Consent Form and Instruction
Form 0920-0260 Employees - HHE Specific Questionnaire Example Form and Instruction
Form 0920-0260 Employees - HHE specific interview example Form and Instruction
PIA form.pdf Supplementary Document
0920-0260_Supporting Statement B.docx Supporting Statement B
0920-0260_Supporting Statement A.docx Supporting Statement A
Attachment A3 60dayFRN.pdf Supplementary Document
Attachment A2.pdf Supplementary Document
Attachment A1.docx Supplementary Document
Employees/ employee representatives/ or employers - HHE Request Form Form and Instruction
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
Employer and Employee Representative - Followback for Onsite Evaluations – Year 1 Form and Instruction
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

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

OMB Details

HHE Specific Worker Questionnaire (Example)

Federal Enterprise Architecture: Health - Illness Prevention

Form none

Specific Worker Questionnaire - example

Paper Only

Form

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