Exothermic Welding Safety Survey
Complete this survey to report exothermic welding experience, safety practices, hazards, and improvement needs.
Respondent and Worksite Information
Respondent Name
*
First Name
Middle Name
Last Name
Job Title / Role
*
Company or Department
*
Worksite / Location
*
Date of Survey
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Exothermic Welding Experience and Training
Years of Experience with Exothermic Welding
*
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
Formal Exothermic Welding Training Completed
*
Yes
No
Training Recency
Within the last 6 months
6-12 months ago
1-2 years ago
More than 2 years ago
Not applicable
Confidence Level Performing Exothermic Welding Safely
*
Not confident
1
2
3
4
5
6
7
8
9
Very confident
10
1 is Not confident, 10 is Very confident
Safety Equipment, Procedures, and Work Conditions
Personal protective equipment used
*
Helmet/face shield
Gloves
Flame-resistant clothing
Safety boots
Hearing protection
Eye protection
Other
Compliance with pre-job inspection and safe setup practices
*
1
2
3
4
5
Hazard control rating
*
Rows
Excellent
Good
Fair
Poor
Workspace ventilation
1
2
3
4
Ignition source control
5
6
7
8
Material storage
9
10
11
12
Exclusion zone setup
13
14
15
16
Equipment condition
*
Please Select
Excellent
Good
Fair
Poor
Out of service
Work area conditions
*
Please Select
Clean and organized
Generally acceptable
Partially obstructed
Poor housekeeping
Unsafe conditions present
Standard operating procedures available and followed
*
Available and followed
Available but not fully followed
Not available
Not sure
Comments on safety equipment, procedures, or work conditions
Hazards, Incidents, and Follow-up
Did any hazard, near-miss, or incident occur during exothermic welding work?
*
No
Yes
Describe the hazard, near-miss, or incident
Observed hazards
Sparks
Burns
Fumes
Improper grounding
Poor ventilation
Damaged molds/tools
Nearby combustibles
Emergency preparedness readiness
*
1
2
3
4
5
Suggestions for improving safety and follow-up actions
Submit Survey
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