Employee Health and Safety Evaluation Form
Please complete the following evaluation to help us ensure a safe and healthy work environment.
Employee Full Name
First Name
Last Name
Department
Please Select
Human Resources
Operations
Sales
Maintenance
IT
Finance
Customer Service
Date of Evaluation
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
On a scale of 1 to 5, how would you rate the safety conditions in your work area?
1
1
2
3
4
Best
5
1 is , 5 is Best
Have you experienced any health or safety incidents recently?
Yes
No
If yes, please describe the incident(s)
Are there any safety improvements or suggestions you would like to recommend?
Do you feel adequately trained for your job's health and safety requirements?
Yes
No
Additional comments or concerns
Submit
Should be Empty: