Health Hazard Evaluations/Technical Assistance and Emerging Problems

Forms and Documents

Document Name	Status
HHE Specific Worker Questionnaire (Example) Form	Modified
Employee Contact Information Postcard - example Form	New
Final Followback Report for Site-visits Year 1 Form	Modified
Followback for Site-visit Evaluations Year 2 Form	Modified
Followback without Site-visit Evaluation Year 2 Form	Modified
Followback without Site-visit Evaluation Year 1 Form	Modified
Initial Site-visit Followback Survey Year 1 Form	Modified
HHE Specific Interview (Example) Form	Modified
Health Hazard Evaluation Request Form for Employees and Employers Form	Modified
Attachment D2.docx Supplementary Document	2014-08-27
Attachment D1.pdf Supplementary Document	2014-08-27
Attachment B.pdf Supplementary Document	2014-08-27
Attachment A2.pdf Supplementary Document	2014-08-27
Attachment A1.docx Supplementary Document	2014-08-27
0920-0260_Supporting Statement B.doc Supporting Statement B	2014-08-27
0920-0260_Supporting Statement A.docx Supporting Statement A	2014-08-27

IC Document Collections

IC ID	Document Title	Status
37747	HHE Specific Worker Questionnaire (Example) Form	Modified
212840	Employee Contact Information Postcard - example Form	New
185724	Final Followback Report for Site-visits Year 1 Form	Modified
185723	Followback for Site-visit Evaluations Year 2 Form	Modified
185722	Followback without Site-visit Evaluation Year 2 Form	Modified
185721	Followback without Site-visit Evaluation Year 1 Form	Modified
185720	Initial Site-visit Followback Survey Year 1 Form	Modified
185719	HHE 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: 201408-0920-011
Status: Historical Active	Previous ICR Reference No: 201109-0920-006
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: 11/17/2014
	Date Received in OIRA: 09/09/2014
Terms of Clearance: Previous terms of clearance continue: 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	11/30/2017	36 Months From Approved	11/30/2014
Responses	9,931	0	8,160
Time Burden (Hours)	3,019	0	2,874
Cost Burden (Dollars)	0	0	0

---

Abstract: PL 91-596 and PL 91-173 mandate that the National Institute for Occupational Safety and Health respond to requests for Health Hazard Evaluations (HHEs) to address chemical, biological, and/or physical workplace hazards. Responses require a valid written response; NIOSH receives about 300 requests per year. The diversity of requests precludes set questionnaires for the evaluations; a set of questionnaires for follow-back is used to assess HHE program effectiveness. Requests come from companies involving service, manufacturing, health and social services, transportation, construction, agriculture/mining, and skilled trades. CDC requests minor revisions to data collection forms and the addition of an employee contact postcard.

---

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

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 19337	04/08/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 51338	08/28/2014
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 9

IC Title	Form No.	Form Name
Employee Contact Information Postcard - example	none	Employee Contact Information Postcard
Health Hazard Evaluation Request Form for Employees and Employers	none, none	HHE Request Form for employees and employers ,   HHE Request form
HHE Specific Interview (Example)	none	HHE Specific Interview - example
Initial Site-visit Followback Survey Year 1	none	Initial Site-visit Followback Survey
Followback without Site-visit Evaluation Year 1	none	Followback without Site-visit Evaluation Year 1
Followback without Site-visit Evaluation Year 2	none	Followback without Site-visit Evaluation Year 2
Followback for Site-visit Evaluations Year 2	none	Final Followback Survey for Site-visits Year 2
HHE Specific Worker Questionnaire (Example)	none	HHE Specific Worker Questionnaire - example
Final Followback Report for Site-visits Year 1	none	Final Followback Survey Report for Site-visits

---

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	9,931	8,160	0	1,771	0	0
Annual Time Burden (Hours)	3,019	2,874	0	145	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: This revision includes minor changes to data collection forms, new estimates of the number of Health Hazard Evaluations and respondents, and the addition of an employee contact postcard. The total burden estimate in the supporting statement is off by 1 due to rounding.

---

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

---

Common Form ICR:  No

---

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: 09/09/2014

---