Workplace Health and Safety Survey (DSG-ProF001)

1

DSG-Pro Subscriber Number

2

H&S Component of a Performance EvaluationSpecial arrangement made through DSG-Pro Services

YES

NO

3

Name(Optional)

First Name

Last Name

4

Email(Optional)

OPTIONAL - Please provide your email address if you'd like to receive a copy of your survey submission

5

Can we add you to our DSG-mailing list for our SAFETY-FIX newsletter, updates and announcements?

I'm okay with being added to the DeBoer Safety Group email list.

No, please don't add me to the list but still send my survey submission. Thanks!

6

Date of Survey Completion* This field is required.If you are attending a DSG-Training Session, we'll be able to capture your responses and review them during the session.

Enter today's date.

7

Employer Finder (optional)

8

Which best describes your industry?* This field is required.Choose your industry-sector, from the list below.

Select an option that best describes your industry

9

Which best describes your company?* This field is required.

Single site (only 1 location of operation)

Multi-site (more than 1 location)

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How many people work at your location?* This field is required.

11

What best describes your role?* This field is required.

I am a ...

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Position* This field is required.Job Title or Job Description

Describe the job that you do and/or your provide your title (i.e. Operator, or H&S Manager)

15

SAFETY-RANKING

16

RANKNo.

18

OPTIONAL - If you chose better enforcement, would you accept discipline from your Supervisor/Manager for a safety-related matter, if needed?

Yes

No

19

1. What, in your opinion, is the #1 hazard in your workplace (for you and your coworkers)?* This field is required.

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1.1 Please select the best "Hazard Category" that would best describe the accident/injury you described.* This field is required.SELECT the category that best fits your previously identified hazard

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1.2 Do you feel that this hazard is CONTROLLED (as much as reasonably possible) at your workplace?* This field is required.

Yes

No

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1.3 What, in your opinion, would be an additional measure to PREVENT an accident/injury from this hazard?* This field is required.There is no wrong answer here. Describe an additional control measure to REDUCE the risk of injury.

23

Have you ever been injured at work?* This field is required.Your answer to this question WILL NOT be shared with your Employer or Supervisor. Your privacy is important to us!

Yes

No

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What area of the body have you injured? (optional)

OPTIONAL

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2. What, in your opinion, is the worst accident/injury that could happen to you (while at work)?* This field is required.ANTICIPATE

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2.1 Please select the best "Hazard Category" that would best describe the accident/injury you just described.* This field is required.SELECT the category that best fits your ANTICIPATED hazard.

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What area of the body would be injured?* This field is required.

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2.1a What would be the worst injury CONSEQUENCE that could happen from the accident you described above (to you, or others)?* This field is required.You are assessing one-risk component here ...

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2.1b How LIKELY is it, that this worst accident/injury could happen (to you, or others)?* This field is required.You are assessing the 2nd component of risk here ...

1
2
3
4

Unlikely

Very likely

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RR-Calculation

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RISK RANKINGYou've assessed that CONSEQUENCE x LIKELIHOOD result in a ranked hazard (see below).

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2.2 Do you feel that this type of accident/injury is CONTROLLED (as much as reasonably possible) at your workplace?* This field is required.Given the RISK-RANKING (previously assessed).

Yes

No

33

2.3 What, in your opinion, would be an additional measure to PREVENT this type of accident/injury?* This field is required.What could be done fo reduce the RISK; either reduce that CONSEQUENCES or the LIKELIHOOD.

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IRS: Self-Assessment

36

IRS:SelfNumber

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IRS: Co-Worker Assessement

39

IRS:CoNumber

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I feel that my supervisor(s) and management/owners take workplace safety seriously, in my workplace.* This field is required.

41

IRS: Leadership Assessment

42

IRS:LeadNumber

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I make it a point to find out about potential dangers in my work and at my workplace.* This field is required.

44

IRS: Hazard Awareness Self Assessment

45

IRS:HazSelfNumber

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I feel comfortable enough to bring health and safety issues to my supervisor(s) and management/owners, in my workplace.* This field is required.

47

IRS: Workplace Participation Assessment (Initiative)

48

IRS:ParticipationNumber

49

If I were asked to do a job, which I felt was unsafe, I would refuse to do it and talk to my supervisor.* This field is required.

50

IRS: Work Refusal/Participation Assessment (Intervention)

51

IRS:WorkRefusal

52

My employer has documented safety policies, rules and procedures which are available to me* This field is required.

YES

NO

54

In my opinion, my employer's safety policy, rules and procedures are relevant to my work and easy to follow* This field is required.

56

IRS: OHS Standards Awareness

57

OHS:StdsNumber

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I think that my province/state's safety laws and regulations adequately protect me at work.* This field is required.

59

OHS-System - Effectiveness

60

OHS:EffectiveNumber

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I think that my province/state's safety laws and regulations are effectively enforced (by government agencies).* This field is required.

62

OHS-System - Enforcement

63

OHS:EnforcementNumber

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I have had interactions with inspectors enforcing my province/state's safety laws and regulations.* This field is required.

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OHS-System Experience

66

OHS:ExpNumber

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H&S CULTURE CORRECTION

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H&S CULTURE SCOREAs assessed by the individual completing the form

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Correlation (Agreement): InitRANK & Workplace IRS:AssessmentAssessment confidence measure, for validation of the following SCORES and INDICES

0.81 is the threshold for validation/confidence in the study

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CONFIDENCE RtnFor validation of the individual's responses as part of a SAFETY-Performance Evaluation; 0.81 is threshold, std.dev (from testing has been calc'd as 0.09)

71

WEIGHTED: H&S Acknowledgement, Familiarity and Utilization Measure (Employer Safety Programs)

LOW < 1, MOD = 1, HIGH > 1.5

72

H&S ENGAGEMENT SCORE

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Likely H&S Participator VALUATIONH&S Engagement INDEX > 60% = 1, H&S Engagement INDEX < 60% = 0

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H&S Participator VALUATION

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Predictive Measure: INDIVIDUAL H&S Knowing vs Doing 'Interest' QUALIFIER

76

WHS-CAPABILITYto Pass to Supervisory Self Assessment

77

Perceived PREVENTION INDEX

78

H&S Culture INDEX

79

H&S Engagement INDEX

80

H&S CAPABILITY - MODIFIED by AUTHA modulator that levels interest (function of ACK,FAM,UTILITY) and the ability to make change ('authority')

81

Individual H&S Contribution / Participation Capacity & Capability SCOREA likelihood of participation and action within an OHS Managed system indicator

82

WHS-Overallto Pass to Supervisory Self Assessment

83

Do you have any additional concerns or comments?If you found this survey helpful, let us know ... We'd love to here from you.

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