Health Hazard Evaluations/Technical Assistance and Emerging Problems

Forms and Documents

Document Name	Status
Health Hazard Evaluation Specific Questionnaire (Example) Form	Modified
Followback for Onsite Evaluations Year 1 Form	Modified
Followback for Onsite Evaluations Year 2 Form	Modified
Follow-back without Onsite Evaluation Year 2 Form	Modified
Follow-back without Onsite Evaluation Year 1 Form	Modified
Initial and Follow-back for Onsite Evaluations Year 1 Form	Modified
Health Hazard Evaluation Specific Interview (Example) Form	Modified
Health Hazard Evaluation Request Form for Employees and Employers Form	Modified
Section B.doc Supporting Statement B	2011-09-20
Attachment D3.docx Supplementary Document	2011-09-20
Attachment D2- bio specimens.docx Supplementary Document	2011-09-20
Attachment D1.pdf Supplementary Document	2011-09-20
Attachment B 60 day FRN.pdf Supplementary Document	2011-09-20
Attachment A3.docx Supplementary Document	2011-09-20
Attachment A2.docx Supplementary Document	2011-09-20
Attachment A1.docx Supplementary Document	2011-09-20
Attachment C- Spanish version.docx Supplementary Document	2011-09-22
Section A.docx Supporting Statement A	2011-09-23

IC Document Collections

IC ID	Document Title	Status
37747	Health Hazard Evaluation Specific Questionnaire (Example) Form	Modified
185724	Followback for Onsite Evaluations Year 1 Form	Modified
185723	Followback for Onsite Evaluations Year 2 Form	Modified
185722	Follow-back without Onsite Evaluation Year 2 Form	Modified
185721	Follow-back without Onsite Evaluation Year 1 Form	Modified
185720	Initial and Follow-back for Onsite Evaluations Year 1 Form	Modified
185719	Health Hazard Evaluation Specific Interview (Example) Form	Modified
185718	Health Hazard Evaluation Request Form for Employees and Employers Form	Modified

ICR Details

OMB Control No: 0920-0260	ICR Reference No: 201109-0920-006
Status: Historical Active	Previous ICR Reference No: 200807-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Health Hazard Evaluations/Technical Assistance and Emerging Problems
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/17/2011
	Date Received in OIRA: 09/27/2011
Terms of Clearance: Previous terms of clearance continue: Approved consistent with the following terms of clearance: approved for purposes of conducting investigations/evaluations, given the anecdotal nature of gathered data information obtained through these collections of information will not be used to develop estimates related to health or safety risks in general.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2014	36 Months From Approved	01/31/2012
Responses	8,160	0	11,690
Time Burden (Hours)	2,874	0	4,007
Cost Burden (Dollars)	0	0	0

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Abstract: PL 91-596 and PL 91-173 mandate that CDC's National Institute for Occupational Safety and Health (NIOSH) respond to request for Health Hazard Evaluations (HHEs) to address chemical, biological, and/or physical workplace hazards. CDC requests revisions to data collection forms for the Health Hazard Evaluation/Technical Assistance and Emerging Problems information collection.

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Authorizing Statute(s): PL: Pub.L. 91 - 173 301 Name of Law: Federal Mine Safety and Health Act
   US Code: 42 USC 85 Name of Law: Public Health Service Act
   PL: Pub.L. 91 - 596 20 Name of Law: Occupational Safety and Health Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 40917	07/12/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 58515	09/21/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
Health Hazard Evaluation Request Form for Employees and Employers	none	HHE Request Form
Health Hazard Evaluation Specific Interview (Example)	none	HHE Evaluation Ineview
Initial and Follow-back for Onsite Evaluations Year 1	none	HHE Initial and Follow-back
Health Hazard Evaluation Specific Questionnaire (Example)	none	HHE Evaluation
Follow-back without Onsite Evaluation Year 1	none	Followback no onsite Year 1
Follow-back without Onsite Evaluation Year 2	none	Follow-back no onsite Year 2
Followback for Onsite Evaluations Year 2	none	Followback Year 2
Followback for Onsite Evaluations Year 1	none	Followback Year 1

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	8,160	11,690	0	-3,530	0	0
Annual Time Burden (Hours)	2,874	4,007	0	-1,133	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The revisions made in this package are re-wording and re-ordering of questions contained in the five Followback questionnaires to improve the ease of responding by the questionnaire recipients. Similar changes have been made to the Health Hazard Evaluation (HHE) request forms in both the English and Spanish versions.

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Annual Cost to Federal Government: $450,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/27/2011

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