Safety Protocol Science Assessment Form
Evaluate your understanding of science safety protocols and procedures.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Role
*
Please Select
Student
Teacher
Lab Assistant
Other
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate your level of agreement with the following safety statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I know the location of emergency exits.
1
2
3
4
5
I understand how to use a fire extinguisher.
6
7
8
9
10
I always wear appropriate personal protective equipment (PPE).
11
12
13
14
15
I know the procedure for reporting an accident.
16
17
18
19
20
I am familiar with the chemical spill protocol.
21
22
23
24
25
What is the correct order of steps if a chemical spill occurs?
*
Evacuate area, notify supervisor, contain spill if safe
Ignore spill, continue working, report later
Clean up immediately without notification
Other
Which of the following items should always be worn in the laboratory? (Select all that apply)
*
Safety goggles
Closed-toe shoes
Lab coat
Loose jewelry
Other
Rate your confidence in handling lab emergencies.
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
How likely are you to ask for help if you are unsure about a safety procedure?
*
Very unlikely
1
2
3
4
Very likely
5
1 is Very unlikely, 5 is Very likely
Please provide any additional comments or suggestions regarding laboratory safety protocols.
Submit Assessment
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