Full Name:

[Name]

Department:

Role/Position:

Contact Details:

1. How would you rate the overall safety of your workplace?

• Excellent

• Good 

• Average

• Poor

• Very Poor

2. Have you received adequate training on health and safety?

• Yes

• No

3. If no, please specify the areas where you need more training:

4. How often are safety drills conducted in your department?

• Weekly

• Monthly

• Quarterly

• Annually

• Never

1. Have you witnessed or experienced any health or safety incidents in the last [6 months]?

• Yes

• No

2. If yes, please provide a brief description of the incident(s):

3. Were these incidents reported?

• Yes

• No

4. If no, please explain why:

1. Are the provided health and safety resources (first aid kits, emergency exits, etc.) easily accessible?

• Yes

• No

2. Do you have any suggestions for additional resources or improvements?

1. How often do you experience work-related stress?

• Always

• Often

• Sometimes

• Rarely

• Never

2. Do you feel that there are adequate measures in place to support mental health?

• Yes

• No

3. If not, what kind of support would you find beneficial?

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