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Request for a Health Hazard Evaluation This form also is available at https://www.cdc.gov/niosh/hhe/request.htmlForm Approved OMB No. 09200260 Exp. 03/31/2024Workplace Name___ Workplace Address ___State

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How to fill out health hazard evaluation request

01

Download the health hazard evaluation request form from the appropriate government agency's website.

02

Fill out your personal information including name, address, and contact information.

03

Describe the health hazard or concern in detail, including any symptoms or illnesses experienced.

04

Provide information on the workplace or environment where the health hazard occurred.

05

Submit the completed form according to the instructions provided by the agency.

Who needs health hazard evaluation request?

01

Employees who believe they have been exposed to health hazards in the workplace.

02

Employers who want to ensure the safety and health of their employees.

03

Health and safety professionals conducting risk assessments in various industries.

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What is health hazard evaluation request?

Health hazard evaluation request is a formal request made to evaluate potential health hazards in a specific environment or situation.

Who is required to file health hazard evaluation request?

Any organization or individual who suspects potential health hazards in their workplace or environment is required to file a health hazard evaluation request.

How to fill out health hazard evaluation request?

Health hazard evaluation request can usually be filled out online or in person by providing detailed information about the suspected hazards and the environment.

What is the purpose of health hazard evaluation request?

The purpose of health hazard evaluation request is to identify and assess potential health risks in order to implement necessary safety measures to protect individuals from harm.

What information must be reported on health hazard evaluation request?

Information such as the nature of the suspected hazards, location, potential affected individuals, and any supporting evidence must be reported on a health hazard evaluation request.

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