Workplace Safety Behavior Assessment Questionnaire Form
Please complete this assessment to help us evaluate and improve workplace safety behaviors and culture. Your feedback on safe work practices, incident prevention, and safety awareness is valuable.
How often do you follow established safety procedures while performing your duties?
*
Always
Often
Sometimes
Rarely
Never
Rate your overall awareness of potential hazards in your work area.
*
1
2
3
4
5
Which of the following safety practices do you regularly observe? (Select all that apply)
*
Wearing required personal protective equipment (PPE)
Reporting unsafe conditions
Following lockout/tagout procedures
Participating in safety meetings or training
Maintaining clean and organized workspaces
Other
In the past month, how many safety incidents or near-misses have you observed or been involved in?
*
How confident are you that management prioritizes safety in the workplace?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
If you identify a safety concern, how comfortable do you feel reporting it?
*
Very comfortable
Somewhat comfortable
Neutral
Somewhat uncomfortable
Very uncomfortable
Please indicate your agreement with the following statements about workplace safety.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I have received adequate safety training.
1
2
3
4
5
Safety rules are clearly communicated.
6
7
8
9
10
Coworkers encourage each other to work safely.
11
12
13
14
15
Which area do you believe needs the most improvement for workplace safety?
Please Select
Equipment maintenance
Employee training
Hazard communication
Incident reporting
PPE availability
Other
Describe any recent positive safety behaviors or initiatives you've observed.
Do you have any suggestions to improve workplace safety?
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