Form 0920-0260 Followback Survey – After HHE Final Letter

Form Approved OMB No.: 0920-0260

Expiration Date:xx/xx/20xx

Followback Survey – After the Health Hazard Evaluation Final Letter

NIOSH wants to know what you think about 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 secure according to federal laws. We will report only summary information and will not identify you.

Please fill in circles completely like this:
How helpful was the final letter?	Extremely helpful Very helpful Moderately helpful Slightly helpful Not at all helpful
Please explain your answer about the final letter.
What do you think about the NIOSH health hazard evaluation?	It was Excellent It was Good It was Fair It was Poor
What, if anything, would have made it better?
How well did the NIOSH recommendations address the issues described in the HHE request?	Very well Fairly well Not very well Not well at all No recommendations were made
Overall, do you think the NIOSH recommendations are practical?	Yes No Recommendations were not made I don’t know
Did the employer post the final letter at the workplace?	Yes No Not applicable - NIOSH did not send the final letter to the employer
Did you share the final letter with others at the workplace?	Yes No
Are you still associated with the workplace that NIOSH evaluated?	Yes No

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 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 Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-0260).

Followback Survey Form 2A 12/12/2023

Thank you for completing this survey!

Call the Followback Coordinator at 513-841-4382 if you have questions or comments.