WORKPLACE INCIDENT FEEDBACK QUESTIONNAIRE

This questionnaire is designed by [Your Company Name] to gather feedback on workplace incidents to improve safety and work environment quality. Your honest and detailed responses are crucial for us to implement effective changes.

Personal Information

Full Name:   [Your Name]                                                          

Employee ID:                                                                                                           

Department:                                                                                                            

Date of Incident:                                                                                                     

Time of Incident:                                                                                                     

Incident Details

Type of Incident (Select one):

• Work Injury

• Equipment Malfunction

• Safety Hazard

• Others (Please Specify): _____________________

Location of Incident:

                                                                                                                                        

Brief Description of the Incident:

                                                                                                                                        

Immediate Action Taken:

                                                                                                                                        

Did you require medical attention?

• Yes

• No

Time taken to respond:

                                                                                                                                        

Adequacy of first aid or medical support provided:

• Sufficient

• Insufficient

• Not Applicable

Suggestions for Preventing Similar Incidents:

                                                                                                                                        

General Feedback

Overall, how safe do you feel in your workplace? (1-5):

                                                                                                                                        

Additional comments or suggestions:

                                                                                                                                        

Thank you for completing the Workplace Incident Feedback Questionnaire. Your feedback is vital for [Your Company Name] in ensuring a safer and more efficient work environment.

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