Safety Control Reference Survey
Please complete this survey to help us assess and improve our safety control standards.
Your Full Name
*
First Name
Last Name
Your Role/Position
*
Department or Area Assessed
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate the following safety control measures:
*
Rows
Not Implemented
Partially Implemented
Fully Implemented
Not Applicable
Emergency Exits Clearly Marked
1
2
3
4
Fire Extinguishers Accessible
5
6
7
8
Personal Protective Equipment Available
9
10
11
12
Safety Signage Displayed
13
14
15
16
Regular Safety Training Conducted
17
18
19
20
How effective do you find the current safety procedures?
*
1
2
3
4
5
Are all staff aware of the safety protocols?
*
Yes
No
Somewhat
Have any safety incidents occurred in the past 12 months?
*
Yes
No
If yes, please describe the incident(s) and corrective actions taken.
Which safety control area requires the most improvement?
*
Please Select
Emergency Preparedness
Equipment Maintenance
Employee Training
Housekeeping
Other
Please share any additional comments or suggestions regarding safety controls.
Submit Survey
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