Health & Safety Committee Survey

Full Name (Optional)	[Your Name]
Department/Team	[Department/Team]
Job Title	[Your Title]
Length of Employment	[0 years]
Office/Branch (if applicable)	[Office/Branch]

Health & Safety Concerns

On a scale of 1 to 5, with 1 being "Not Concerned" and 5 being "Very Concerned," please rate your level of concern regarding health and safety in the workplace.

• 1

• 2

• 3

• 4

• 5

Please list any specific health and safety concerns or issues you have encountered or observed in the workplace:

Committee Involvement

Are you interested in being a member of the Health & Safety Committee?

• Yes

• No

If you answered "Yes" to question 8, please indicate your reasons for wanting to join the committee and any relevant experience or qualifications you may have:

Committee Preferences

What topics or areas of health and safety would you like the committee to focus on? (e.g., ergonomics, hazard identification, first aid, mental health, etc.)

How often would you prefer the Health & Safety Committee to meet?

• Monthly

• Quarterly

• Annually

• Other (please specify): [Open Text Field]

What time of day would be most convenient for you to attend committee meetings?

• Morning

• Afternoon

• Evening

Additional Comments

Please provide any additional comments, suggestions, or ideas related to health and safety that you would like the committee to consider:

Contact Information (Optional)

If you are willing to be contacted for further discussion or clarification, please provide your preferred contact information:

Email Address: [Your Email]

Phone Number: [Your Company Number]

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