NIOSH Health Hazard Evaluations (HHEs)

	Health Hazard Evaluations

Request an HHE Form

Request an HHE.

Form Approved OMB No. 0920-0260 Expires November 30, 2007

To request a health hazard evaluation, please fill out the following form.

Establishment Where Possible Hazard Exists

Company Name:

Address:

What product or service is provided at this workplace?

Specify the particular worksite, such as building or department, where the possible hazard exists:

How many people are exposed?

Duration of exposure (hours/day)?

What are the occupations of the exposed employees?

What is the process/task?

To your knowledge, has NIOSH, OSHA, MSHA, or any other government agency previously evaluated this workplace?

Yes No

Is a similar request currently being filed with, or is the problem under investigation by any other local, state, or federal agency?

Yes No

If either of the two preceding questions is answered yes, give the name and location of each agency.

What is the name of the company official who is responsible for employee health and safety?

Title

Phone

Description of the Possible Hazard or Problem

Please list all substances, agents, or work conditions which you believe may contribute to the possible health hazard. (Include chemical name, trade name, manufacturer or other identifying information, as appropriate.)

In what physical form(s) do(es) the substance(s) exist? Please specify either dust, gas, liquid, mist, or other.

How are the affected employees exposed (route of exposure)? Please specify breathing, skin contact, swallowing, or other.

What health problem(s) do employees have as a result of these exposures?

Use the space below to supply any additional relevant information.

Requestor's name (Your signature may be requested to process this HHE request.) (Required)

Should requestor's name be kept confidential?

Yes
No

Address:

E-mail Address: (Required)

Business phone

Home phone

Best time of day to call:

Indicate yes to the one category that best describes your connection to the workplace where the exposures are found.

I am an employer representative.
I am an authorized representative of, or an officer of the union or other organization representing the employees for collective bargaining purposes.
I am a current employee of the employer.
Other: Please describe:

You can also send the completed form to:

National Institute for Occupational Safety and Health
Hazard Evaluation and Technical Assistance Branch
4676 Columbia Parkway, R-9
Cincinnati, Ohio 45226

Or fax this request form to: (513)841-4488

Statement of authority: Sections 20(a)(3-6) of the Occupational Safety and Health Act (29 USC 669(a)(6-9), and Section 501(a)(11) of the Federal Mine Safety and Health Act (30 USC 951(a)(11)). Confidentiality of the respondent requester will be maintained in accordance with the provisions of the Privacy Act (5 USC 552a). The voluntary cooperation of the respondent requester is required to initiate the Health Hazard Evaluation.

This form is provided to assist in requesting a health hazard evaluation from the U.S. Department of Health and Human Services. Public reporting burden for this collection of information is estimated to average 12 minutes per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to PHS Reports Clearance Officer, ATTN: PRA, Hubert H. Humphrey Bldg., Rm. 721-B, 200 Independence Ave., SW, Washington, D.C., 20503.

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