Health & Safety Committee Feedback Form

Your safety matters! We value your insights to enhance our workplace health and safety. Please take a moment to share your feedback with the Health & Safety Committee.

Name:	[Your Name]
Department:	[Operations]
Position:	[Job Title]
Contact Number:	[Your Contact Information]
Email Address:	[Your Email]

I. General Feedback

A. Overall Perception

On a scale of 1 to 5, where 1 is "Not Effective" and 5 is "Highly Effective," please rate your overall perception of the effectiveness of health and safety measures in the workplace.

• 5

• 4

• 3

• 2

• 1

B. Comments

We appreciate your rating! Please provide detailed comments or suggestions regarding the overall state of health and safety in the workplace:

II. Specific Areas of Concern

A. Emergency Procedures

Please rate the effectiveness of emergency procedures, including evacuation plans and fire drills.

• 5

• 4

• 3

• 2

• 1

B. Training Programs

-                                                                                                                                        

-                                                                                                                                        

C. Safety Equipment

-                                                                                                                                        

-                                                                                                                                        

III. Incident Reporting

A. Incident/Near-Miss Reporting

Have you encountered or observed any incidents or near-misses recently? If yes, please provide details:

-                                                                                                                                        

-                                                                                                                                        

B. Reporting Process

How would you rate the ease of use and efficiency of the incident reporting process?

• 5

• 4

• 3

• 2

• 1

IV. Suggestions for Improvement

Please provide any additional comments or suggestions for improving health and safety in the workplace:

-                                                                                                                                        

-                                                                                                                                        

V. Follow-up

A. Action Items

Have you observed any actions taken by the Health & Safety Committee as a result of previous feedback? If yes, please provide details:

-                                                                                                                                        

-                                                                                                                                        

B. Further Assistance

Do you require further assistance or clarification regarding health and safety matters? If yes, please specify:

-                                                                                                                                        

-                                                                                                                                        

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