Health Hazard Evaluations – Request an HHE : Summary
Dear [SN],
The following information has been submitted to NIOSH Health Hazard Evaluation Program:
Workplace Name
[WN]
Workplace Address
[WA]
What type of work is done at this location?
[TW]
How many people work at this location?
[NL]
Who is responsible for employee health and safety in this workplace?
Name
[NP]
Title
[TP]
Phone number
[PN]
What hazardous substances, agents, or work conditions are of concern?
(If known, please include chemical names, trade names, manufacturer names, or other identifying information.)
[HH]
How are employees exposed?
[EE]
Other: [XE]
In what work area, such as a building or department, is the hazard?
[HA]
How many people work in this area?
[NW]
Describe the work people do in this area.
[WD]
What health concerns do people in this work area have?
[HC]
Information about you
Name:
[SN]
Address where we can send you information:
[SA]
Phone number where you would like to be called:
[SP]
Best time to call:
[ST]
Email address where you would like to be contacted:
[SE]
Can NIOSH reveal your name to the employer?
[CN]
Please check one:
[RE]
Other Relationship: [XR]
Second employee
Name:
[N2]
Address where we can send you information:
[A2]
Phone number where you would like to be called:
[P2]
Best time to call:
[T2]
Email address where you would like to be contacted:
[E2]
Can NIOSH reveal this name to the employer?
[CN2]
Third employee
Name:
[N3]
Address where we can send you information:
[A3]
Phone number where you would like to be called:
[P3]
Best time to call:
[T3]
Email address where you would like to be contacted:
[E3]
Can NIOSH reveal this name to the employer?
[CN3]
Complete this section if you are a union representative
Name of union:
[UN]
Address:
[UA]
What is your position in the union?
[UP]
Complete this section if you are an employer representative
Name:
[RN]
What is your position in the company, agency, or organization?
[RP]
For everyone
Has another government agency evaluated this workplace?
[OE]
If yes:
What agency?
[ON]
What year was the evaluation done?
[EY]
Check here if this evaluation is underway now
[ES]
Is a request for the hazard being filed with another agency?
[IR]
If yes:
What agency?
[NG]
How did you learn about the NIOSH Health Hazard Evaluation Program?
[LH]
Learned about from other source: [XL]
Thank you for submitting this form. You will get a response within 10 days.