Request for a Health Hazard Evaluation
Form Approved
OMB No. 0920-0260
This form also is available at
Exp. 11/30/2017
Workplace Name______________________________________________________________________________
Workplace Address ____________________________________________________________________________
Street
City
State
Zip Code
What type of work is done at this location? ________________________________________________________
How many people work at this location?
O 3 or less
O 4-9
O 10-49
O 50-99
O 100-249
O 250 or more
Who is responsible for employee health and safety in this workplace?
Name_________________________
Title___________________________ Phone number________________
What hazardous substances, agents, or work conditions are of concern? If known, please include chemical names, trade
names, manufacturer name, or other identifying information.
How are employees exposed?
O Breathing
O Skin Contact
O Swallowing
O Other (Explain :____________________)
In what work area, such as a building or department, is the hazard? _______________________________________
O 10-49
How many people work in this area? O 3 or less O 4-9
O 50-99
O 100-249
O 250 or more
Describe the work people do in this area.
What health concerns do people in this work area have?
Information about you
Name (please print):_______________________________________________
Address where we can send you information? ______________________________________________________
Street
City
State
Zip Code
Phone number where you would like to be called: (_____) __________________
Best time to call: _________________
a.m. or
p.m.
Email address where you would like to be contacted: ________________________________________________
Can NIOSH reveal your name to your employer?
No
Yes
Please check one:
I am a current employee and 3 or fewer employees are exposed to the hazard.
O I am a current employee and more than 3 employees are exposed to the hazard.
If you check this box, two other employees need to sign this form and provide their contact information.
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
Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0260).
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