Form Approved 

OMB No. 0920-0260 

Exp. 01/31/2027

Request for a Health Hazard Evaluation 

This form also is available at https://www.cdc.gov/niosh/hhe/request.html

Workplace Name______________________________________________________________________________ 

Workplace Address ____________________________________________________________________________ 

________________________________________________________ 

O O O O O O 

_________________________ __________________________ ________________ 

O O O O O O 

_______________________________________________ 

______________________________________________________ 

(_____) __________________ 

_________________ 

________________________________________________ 

O 

 Street City State Zip Code 
 

What type of work is done at this location? 

How many people work at this location? 

3 or less 4-9 10-49 50-99 100-249 250 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. 

What health concerns do people in this work area have? 

In what work area, such as a building or department, is the hazard? _______________________________________ 

How many people work in this area? 3 or less 4-9 10-49 50-99 100-249 250 or more 

Describe the work people do in this area. 



Complete this section if you are an employee submitting a request

(See page 2 if you are a union or employer representative) 

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. 

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). 
 

 

 

 

 

 

 

 

 


 


 


 


 


 


 


 


 


 


 

Second employee 

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 

Third Employee 

Name (Please print): 

Address where we can send you information? 

Street City State Zip Code

_________________________________________________ 

_______________________________________________ 

______________________________________________________ 

(_____) __________________ 

_________________ 

_________________________________________________ 

O O 

O 

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 

Complete this section if you are a union representative 

Name of union: ______________________________________________________________________________ 

___________________________________________________________________________________ 

______________________________________________________________ 

_____________________________________________________________________________________ 

_______________________________________ 

Address: 

Street City State Zip Code 

What is your position in the union? 

Complete this section if you are an employer representative 

Name: 

O O O 

_________________________________________________________________________ 

_______________________________________________________ 

O 

No Yes Do not know 

What is your position in the company, agency, or organization? 

For everyone 

Has another government agency evaluated this workplace? 

If yes: 

What agency? 

What year was the evaluation done? 

Check here if this evaluation is underway now 

Is a request for the hazard being filed with another agency? O O O 

_________________________________________________________________________ 

O O 

O O 

No Yes Do not know 
 
 

If yes: 
 
 

What agency? 

How did you learn about the NIOSH Health Hazard Evaluation Program? 

O NIOSH website Facebook Other website (Explain :______________________________________) 

O O 

O 

CDC 1-800 number Union Coworkers Company official 

Trade/industry/union magazine or newsletter O Other (Explain :________________________________) 

 

 







To submit this form by email, save the completed form to your computer and send it as an email attachment 

to HHERequestHelp@cdc.gov. 

To submit this form by fax, send it to (513) 841-4488. 

To submit this form by mail, send it to: National Institute for Occupational Safety and Health 

 1090 Tusculum Ave, MS R-9

 Cincinnati, Ohio 45226-1998

Thank you for submitting this form. You will get a response from us within 10 days.