Un sitio oficial del Gobierno de Estados Unidos
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.
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.