Self Assessment

Safety Culture Assessment

Instructions:

This survey must be completed by a person assessing the Safety Culture of their own organization & department.

A response must be given for all 110 questions.

After completing the questionnaire, please fill out the Additional Information section so that your responses can be properly identified and collated.

At the end of the form, please be sure to click the 'submit' button otherwise your responses will not be recorded.

Please skip to the Additional Information Section

Do Not Designate Feedback Providers:

	First Name:	Last Name:	Email Address:	Phone:
Colleagues & Peers



Direct Reports



Others

Additional Information

For purposes of identifying and collating your responses please provide the following information about yourself:

Please select your Department:

For security purposes please enter a unique ID number. The number should be at least 4 digits long and known only to you:

First (given) Name:

Last (family) Name:

What Company do you work for:

What is your current Department:

What is your Unit:

What is your email address?

For security purposes please enter a unique ID number. The number should be at least 4 digits long, (eg. last 4 digits of SSN or EmpID) and known only to you. It will be used to verify the identity of the person completing this form:

18 to 29 30 to 39 40 to 49 50 to 59 60 to 69
70 to 79
80 +

Please indicate your age bracket?

Please Indicate Your Education Level:

What is your impression of the safety culture in this organization?
What would you suggest for improving the safety culture of this organization?

What is your Gender? Male: Female:

Caucasian Bi-racial Hispanic, Latino/a African-American Asian or
Pacific Islander
American Indian or Native Alaskan
Multi-racial Other
specify below

Which of the following categories best describes your race or ethnicity?

Other Race:

Zero One Two Three Four More

How many injuries have you had in the last three years

Entry-level manager
(i.e., Team Leader) Supervisor Manager Director Executive
Other
specify below

Which of the following best describes your present Position?

Other Position:

How long (full years) have you held this position?

How long (full years) have you worked in this field?

How many accidents have you been involved in during the past three years?

In the past 30 days, how many full days of work have you missed?

How many near misses have you been involved in the last three years?

Full-Time Part-Time

Are you working Full or Part time?

FORM SUBMISSION

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Thank you for completing this assessment!!!

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		Very Strongly Disagree	Strongly Disagree	Disagree	Agree	Strongly Agree	Very Strongly Agree
1.	My company is a safe place to work.
2.	Senior management is commited to employee safety.
3.	Employees take all safety precautions before doing a job.
4.	I know how to spot safety hazards.
5.	My supervisor invests time to keep work safe.
6.	Employees feel free to report safety hazards.
7.	My job is safe from accidents and injuries.
8.	Employee safety is not sacrificed for production during a job.
9.	I have been given my company's safety policies and procedures.
10.	My coworkers are commited to the safety of others.
		Very Strongly Disagree	Strongly Disagree	Disagree	Agree	Strongly Agree	Very Strongly Agree
11.	Unsafe employees are held accountable for thier actions.
12.	My company safety officer provides valuable safety training.
13.	My company is commited to employee safety.
14.	Senior management helps make my company a safer place.
15.	Employees wear appropriate personal protective equipment.
16.	I know how to avoid safety hazards.
17.	My supervisor invests time to improve employee safety.
18.	Employees are encouraged to fix or report safety hazards.
19.	My work in clean and orderly.
20.	Employee safety is not sacrificed for speed during a job.
		Very Strongly Disagree	Strongly Disagree	Disagree	Agree	Strongly Agree	Very Strongly Agree
21.	I understand my company's safety policies and procedures.
22.	My coworkers look out for my safety.
23.	Unsafe employees receive lower performance ratings.
24.	My company safety oficer educates me on employee safety.
25.	My company values employee safety.
26.	Middle management is commited to employee safety.
27.	Employees do not take unnecessary safety risks at work.
28.	I know how to fix or report safety hazards.
29.	My supervisor helps make my company a safer place.
30.	I am encouraged to raise safety concerns.
		Very Strongly Disagree	Strongly Disagree	Disagree	Agree	Strongly Agree	Very Strongly Agree
31.	My work area has been made as safe as possible.
32.	Employee safety is not sacrificed for quality during a job.
33.	My company's safety policies and procedures help make my company a safer place.
34.	My coworkers help make my company a safer place.
35.	Safer employees are promoted more quickly.
36.	My company safety officer influences me to work safely.
37.	Middle management helps make my company a safer place.
38.	Employees wear seat belts when riding in company vehicles.
39.	My company can only be successful if it has a strong safety record.
40.	I pride myself on my ability to work safely.
		Very Strongly Disagree	Strongly Disagree	Disagree	Agree	Strongly Agree	Very Strongly Agree
41.	Safety is more important than productivity.
42.	I hope to be known as a safe worker.
43.	My company personnel usually follow safety guidlines.
44.	Safety at work is as important as safety at home.
45.	I avoid accidents by using safety practices.
46.	The most important part of completing a job is being safe.
47.	I would rather be a safe employee than a productive employee.
48.	Safety errors are handled appropriately by my work unit.
49.	I can prevent and avoid accidents through my personal actions.
50.	I attempt to correct safety hazards at all times.
		Very Strongly Disagree	Strongly Disagree	Disagree	Agree	Strongly Agree	Very Strongly Agree
51.	The best employees are usually the safest employees.
52.	My coworkers see me as a safe worker.
53.	Safe employees should be rewarded.
54.	I understand my company's Safety Management Plan.
55.	I talked with a member of a Safety Commitee (or other appropriate group) about safety during the past 12 months.
56.	I participated in company safety training designed to reduce injuries during the past 12 months.
57.	I participated in company safety training to improve my safety skills during the past 12 months.
58.	I saw evidence of my company's efforts to reward safe work behavior during the past 12 months.
59.	I participated in a job safety briefing before doing a work task during the past 12 months.
60.	I particpated in a pre-task hazard assessment before doing a work task in the last 12 months.
		Very Strongly Disagree	Strongly Disagree	Disagree	Agree	Strongly Agree	Very Strongly Agree
61.	I received a performance documentation or commendation for using SAFE work practices during the past 12 months.
62.	I recieved a performance documentation form or memo for using UNSAFE work practices during the past 12 months.
63.	My manager toured my workplace and encouraged safe work practices during the past 12 months.
64.	My supervisor talked with me about my safety issues during the past 12 months.
65.	My co-workers have given me suggestions about how to work safely.
66.	I feel comfortable giving my co-workers suggestions about how to safely perform the job to improve safety.
67.	I participated in an on-line safety training program or course during the last 12 months.
68.	Safety boots help improve employee safety.
69.	Safety briefings or meetings are held frequently.
70.	Safety meetings help improve employee safety.
		Very Strongly Disagree	Strongly Disagree	Disagree	Agree	Strongly Agree	Very Strongly Agree
71.	The culture of the area I work in allows me to learn from the mistakes of others.
72.	Top leaders in this organization listen to me and care about my concerns.
73.	My concerns about safety would be acted upon if I expressed them to management.
74.	The company is doing more for safety now than it did 1 year ago.
75.	My co-workers frequently disregard safety guidelines that are established for this work area.
76.	Personal safety is constantly reinforced as a priority in the company.
77.	Errors are handled appropriately in my work area.
78.	Leadership is driving us to be a safety focused organization.
79.	There are clear guidelines in place that identify proper channels to report safety concerns.
80.	Most job stress in this company is caused by safety concerns.
		Very Strongly Disagree	Strongly Disagree	Disagree	Agree	Strongly Agree	Very Strongly Agree
81.	My manager demonstrates good safety practices.
82.	Management always keeps safety in mind.
83.	The safety concerns in this company stem from personnel shortages.
84.	The safety concerns in this organization are the result of fatigue issues.
85.	The safety concerns in this organization stem from unclear guidelines regarding work practices .
86.	I wish this was a safer place to work.
87.	Safety concerns in this organization are openly discussed by the staff.
88.	Employees feel comfortable approaching supervisors about safety issues.
89.	Our unit takes the time to identify safety threats.
90.	It will reflect poorly on me if I report safety issues.
		Very Strongly Disagree	Strongly Disagree	Disagree	Agree	Strongly Agree	Very Strongly Agree
91.	Safety errors and near misses frequently go unreported in my unit.
92.	I have few friends at work that I can talk to if I make an error or have a near miss.
93.	Safety decisions are made by the appropriate level of management.
94.	Staff that follow safety practices effectively are rewarded and praised.
95.	Loss of experienced staff members has jeopardized safety.
96.	I have sufficient time to work safely.

Please select your Department:
For security purposes please enter a unique ID number. The number should be at least 4 digits long and known only to you:

First (given) Name:
Last (family) Name:
What Company do you work for:
What is your current Department:
What is your Unit:
What is your email address?
For security purposes please enter a unique ID number. The number should be at least 4 digits long, (eg. last 4 digits of SSN or EmpID) and known only to you. It will be used to verify the identity of the person completing this form:

	18 to 29	30 to 39	40 to 49	50 to 59	60 to 69	70 to 79	80 +
Please indicate your age bracket?

	Caucasian	Bi-racial	Hispanic, Latino/a	African-American	Asian or Pacific Islander	American Indian or Native Alaskan	Multi-racial	Other specify below
Which of the following categories best describes your race or ethnicity?

	Zero	One	Two	Three	Four	More
How many injuries have you had in the last three years

	Entry-level manager (i.e., Team Leader)	Supervisor	Manager	Director	Executive	Other specify below
Which of the following best describes your present Position?

	Full-Time	Part-Time
Are you working Full or Part time?