Followback II

Attachment L OMB #0920-0260

Expir._____

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

U.S. PUBLIC HEALTH SERVICE

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

Health Hazard Evaluation Survey

One Year Later

The National Institute for Occupational Safety and Health (NIOSH) conducts surveys of people with whom we have communicated in conducting work place evaluations. Thank you for responding to the previous survey(s). Now, we are asking your thoughts about the NIOSH evaluation and its effects approximately one year after its conclusion. Please help us by filling out this survey form. Please give your candid answers to the survey questions. We will use this information to help improve our procedures and reports and to learn about the effects of NIOSH evaluations in reducing and preventing work-related illness and injury.

Your responses will be kept in a secure manner according to applicable laws. Our reports will include only summary information and will not identify you in any way.

Please mail completed surveys to NIOSH in the postage paid envelope. If you have any questions or concerns, please call Barbara Jenkins at 513-458-7132.

Thank you!

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-0260).

STATEMENT OF AUTHORITY:

Sections 20(a)(3–6) of the Occupational Safety and Health Act (29 USC 669(a)(6–9), and Section 501(a)(11) of the Federal Mine Safety and Health Act (30 USC 951(a)(11). The identity of the participant will be protected under provisions of the Privacy Act (5 USC). The voluntary cooperation of the participant is required.

NIOSH Health Hazard Evaluation Survey: One Year Later
This survey asks what has happened at the work place in the year since NIOSH completed the health hazard evaluation. Please fill in circles completely like this:
Do you think there is a health hazard at the work place now?		no hazard yes, a mild hazard yes, a moderate hazard yes, a severe hazard don’t know
Do you think NIOSH helped make things better at the work place?		yes no don’t know nothing needed to change
If yes to item 2, please describe the positive changes.
If NIOSH suggested contacting another agency or organization for assistance, did you or anyone else do that?		yes no don’t know no suggestion was made
Recommendations NIOSH made are printed in the left column below. Please mark one response for each item and explain in the box on the right.
Recommendation	Has action been taken?		Please explain your response
5A.	yes no don’t know
5B.	yes no don’t know
5C.	yes no don’t know
5D.	yes no don’t know
5E.	yes no don’t know
Recommendation	Has action been taken?		Please explain your response
5F.	yes no don’t know
5G.	yes no don’t know
5H.	yes no don’t know
5I.	yes no don’t know
5J.	yes no don’t know

Assessment of the Evaluation
6. What is your overall impression of the NIOSH health hazard evaluation?		excellent good fair poor
Please print here any comments that you have about the NIOSH health hazard evaluation.
Did you request the health hazard evaluation?	yes no
Which one of the following best describes your position now?	no longer associated with the work place management health and safety staff union representative supervisory employee nonsupervisory employee government health/safety agent consultant other – please describe: _______________________________
Thank you for taking the time to fill out this survey. We appreciate your cooperation. Please send this form in the enclosed envelope to: Barbara Jenkins, NIOSH R-9, 4676 Columbia Parkway, Cincinnati, OH 45226.

Form 3A (9/07) 5