Safety Perception Survey Form Please enable JavaScript in your browser to complete this form.Company/LocationName *FirstLastEmail *The Management team has made it perfectly clear that safety should never be compromised for the sake of production, quality or any other situation. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeStrongly DisagreeDisagreeDisagreeNeutralNeutralAgreeAgreeStrongly AgreeStrongly Agree Safety, at a minimum, is as important to my immediate supervisor as production, cost or quality is. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree My immediate supervisor does things every day that show s/he is concerned with safety. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree Employees where I work do things every day that show they are concerned with safety. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree I do things every day at work that show I am concerned with safety. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree The management team truly cares about the safety and well being of all employees. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree Employees where I work speak up if they have any concerns regarding someone else’s safety. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree I feel comfortable approaching other employees to discuss any concerns I have about their safety. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree Safety is everyone’s responsibility. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree Employees where I work personally do everything they can, that is within their control, to make sure an unsafe situation is corrected. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree My immediate supervisor follows the safety rules all of the time. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree Employees where I work follow the safety rules all of the time. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree I follow the safety rules where I work all of the time. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree Outside visitors and contractors follow the safety rules all of the time. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree My immediate supervisor thanks me for performing my job safely. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree The management team is fair and consistent when enforcing the safety rules. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree I clearly understand the safety rules where I work. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree I clearly understand the consequences for breaking the safety rules where I work. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree My supervisor encourages us to come forward with safety concerns. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree We do an effective job of thoroughly investigating all safety incidents, including close calls, at my facility. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree Safety information* is shared openly with employees. *Includes: incident investigation results, safety committee meeting minutes, goal progress, etc. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree All injuries are reported regardless of how serious they are. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree The management team promptly provides feedback on safety concerns. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree At any given time, I am able to openly voice my opinions about safety concerns at my facility. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree I believe we can prevent all safety incidents and injuries from occurring in my facility. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree My facility does its best to proactively fix hazards before an incident occurs. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree I am confident in my ability to recognize a safety hazard. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree I know how to react to a safety hazard in order to avoid personal injury. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree My facility overall is a safe place to work * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree I do things everyday outside of work that show I am concerned with safety. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree The following best practices are effective in minimizing incidents at my facility. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree TrainingStrongly DisagreeTraining Strongly DisagreeDisagreeTraining DisagreeNeutralTraining NeutralAgreeTraining AgreeStrongly AgreeTraining Strongly AgreeSafety CommitteeStrongly DisagreeSafety Committee Strongly DisagreeDisagreeSafety Committee DisagreeNeutralSafety Committee NeutralAgreeSafety Committee AgreeStrongly AgreeSafety Committee Strongly AgreeJHAsStrongly DisagreeJHAs Strongly DisagreeDisagreeJHAs DisagreeNeutralJHAs NeutralAgreeJHAs AgreeStrongly AgreeJHAs Strongly Agree We do a good job of getting all employees involved in the safety management system at our facility. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree I would be interested in getting more involved in the safety management system at my facility to help create a safer workplace. * YesNoMaybe at a later date YesItem #1 YesNoItem #1 NoMaybe at a later dateItem #1 Maybe at a later date Safety is an integral part of everything we do at my facility. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree The following safety programs have been effective in helping to minimize incidents at my facility. List programs below.The management team takes personal responsibility for safety at my facility. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree I have at least one specific, measurable, proactive safety goal that I am personally held accountable for that is not related to number of incidents. * YesNoMaybe at a later date YesItem #1 YesNoItem #1 NoMaybe at a later dateItem #1 Maybe at a later date The overall safety management system* at my facility is effective. *Includes: educating employees, controlling hazards and preventing injuries. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree Our plant allocates the proper amount of resources to implement an effective safety management system. * Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Strongly DisagreeItem #1 Strongly DisagreeDisagreeItem #1 DisagreeNeutralItem #1 NeutralAgreeItem #1 AgreeStrongly AgreeItem #1 Strongly Agree Comments and SuggestionsSubmit