Employee Risk Assessment Questionnaire Form
Please complete the Employee Risk Assessment Questionnaire Form to help us evaluate workplace risk factors and improve safety.
Full Name
*
First Name
Last Name
Department
*
Please Select
Operations
Finance
HR
IT
Sales
Marketing
Other
How would you rate the overall safety of your current work environment?
*
1
2
3
4
5
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
I know how to report a safety hazard.
6
7
8
9
10
My workspace is free from obvious hazards.
11
12
13
14
15
I feel comfortable raising safety concerns.
16
17
18
19
20
Which of the following risk factors are present in your work area? (Select all that apply)
Slippery floors
Obstructed walkways
Poor lighting
Unsecured equipment
Excessive noise
None of the above
Other
How frequently do you encounter potential safety risks in your daily work?
*
Never
Rarely
Sometimes
Often
Very often
Do you know whom to contact in case of a workplace emergency?
*
Yes
No
Please describe any additional risks or concerns not listed above.
Suggestions for improving workplace safety
Submit Assessment
Should be Empty: