Environmental Engineering Reference
In-Depth Information
tABle 22.1 (continued)
health hazard evaluation Form
This.form.is.provided.in.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,.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.DHHS.Reports.Clearance.Oficer;.Paperwork.Reduction.Project.(0920-0102);.Rm.531,.
Hubert.H..Humphrey.Building,.200.Independence.Ave.,.SW,.Washington,.D.C..20201..(See.Statement.of.
Authority.on.reverse.)
.16.. What.health.problem(s).do.employees.have.as.a.result.of.these.exposures?.(Please.circle.the.one.of.
most.concern.)..____________________________________________________________________
. . . ________________________________________________________________________________
.17.. Use.the.space.below.to.supply.any.additional.relevant.information... __________________________
.
. . ________________________________________________________________________________
.
. . ________________________________________________________________________________
.
. . ________________________________________________________________________________
Submitting the HHE Request
.18.. Requester's.Signature:..__________________________________________ .Date:..______________
.19.. Type.or.print.name:..________________________________________________________________
.20.. Address:.._________________________________________________________________________
. . City:..______________________________ .State:.________________ .Zip.Code:..______________
.21.. a).Business.phone:.. .b).Home.phone:.._______________________________
. . c).Best.time.of.day.to.call:.. .d).E-mail:..____________________________________
.22.. Check.and.complete.only.one.of.the.following.three.boxes:
□
. I.am.a.
current employee
.of.the.employer,.and.an.
authorized representative of two or more
*
other current employees
.in.the.workplace.where.
the.exposures.are.found..Two.additional.employee.
signature.are.required.for.a.valid.request.
*
Please provide additional signatures.
Signature:..___________________________
Phone:.. _____________________________
E-mail:.._____________________________
.
*.
Additional.signatures.are.not.necessary.if.you.
are.1.of.3.or.fewer.employees.n.the.affected.
workplace.
Signature:..___________________________
Phone:.. _____________________________
E-mail:.._____________________________
Name and address of this organization:
. ___________________________________
. ___________________________________
□
. I.am.an.authorized.representative,.or.an.oficer.of.
the.
union
.or.other.organization.representing.the.
employees.for.collective.bargaining.purposes
□
. I.am.an.employer.representative.
Title:.._______________________________
