Safety Feedback Survey
Help us improve safety by sharing your observations and suggestions.
Full Name
First Name
Last Name
Department or Work Area
*
Please Select
Manufacturing
Warehouse
Office
Maintenance
Other
Role
*
Employee
Supervisor
Visitor
Contractor
Other
Date of Feedback
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate the overall safety in your work area?
*
1
2
3
4
5
Have you observed any unsafe conditions or behaviors recently?
*
Yes
No
If yes, please describe the unsafe condition or behavior.
Have you witnessed or experienced any incidents or near-misses?
*
Yes
No
If yes, please provide details about the incident or near-miss.
Please rate the following aspects of workplace safety.
*
Rows
Excellent
Good
Fair
Poor
Availability of safety equipment
1
2
3
4
Cleanliness and orderliness
5
6
7
8
Clarity of safety signs
9
10
11
12
Response to reported hazards
13
14
15
16
Do you have any suggestions to improve safety?
Would you like to be contacted for follow-up?
*
Yes
No
Email Address (if you wish to be contacted)
example@example.com
Submit Feedback
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