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.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
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

Historical document collections
Reference	Filing	Received	Action
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
Form	Name	Electronic access	Type
Form 0920-0260	Request for a Health Hazard Evaluation - English	N/A	Form and instruction
Form 0920-0260	Request for a Health Hazard Evaluation - Spanish	N/A	Form and instruction

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