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Health Hazard Evaluations (HHEs) - HHE Form

HHE Form

Form Approved OMB No. 0920-0260 Expires November 30, 2017

To request a health hazard evaluation, please fill out the following form.

How many people work at this location?

 

Who is responsible for employee health and safety in this workplace?


 

How are employees exposed?

 

 

How many people work in this area?

 

 

 

Information about you



 

 

Please check one:

 

Second employee


 


 

Can NIOSH reveal this name to your employer?

 

Third employee


 


 

Can NIOSH reveal this name to your employer?

 

 

Complete this section if you are a union representative

 

 

Complete this section if you are an employer representative

 

 

Can NIOSH reveal your name to your employer?

 

For Everyone

Has another government agency evaluated this workplace?

 

If yes:

 

Is a request for the hazard being filed with another agency?

 

If yes:

 

How did you learn about the NIOSH Health Hazard Evaluation Program?

 
 

After selecting 'Send Request Form' below, you will be redirected to a confirmation page
summarizing all entries made on this request.

If you want a copy of this request for your records, please print the confirmation page.

 


If you have questions about this form, call us at (513) 841-4382 or send us an email at HHERequestHelp@cdc.gov.


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)). Confidentiality of the respondent requester will be maintained in accordance with the provisions of the Privacy Act (5 USC 552a). The voluntary cooperation of the respondent requester is required to initiate the Health Hazard Evaluation.


Public reporting burden of this collection of information is estimated to average 12 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).


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