FT Workforce Employee Health and Safety Survey
Completed by (first name):
*
Email address
*
example@example.com
White Card ID number
*
Date of Survey
*
-
Month
-
Day
Year
Date
Client/Host employer:
*
Supervisor (full name):
*
Site Location (address):
*
FT Workforce Representative:
*
Workplace Safety
Please answer the following questions with ‘Yes’ or ‘No’
Does all machinery, tools, and/or equipment you are using have protection from moving parts, electricity & stored energy (guarding)?
*
Yes
No
N/A
Other
Do you operate any machinery or equipment outside of your job-description?
*
Yes
No
N/A
Other
Does all electrical equipment have RCD protection (emergency isolation)?
*
Yes
No
N/A
Other
Are Safe Work Method Statements (SWMS) completed for all High Risk Tasks?
*
Yes
No
N/A
Other
Is all mobile or fixed plant in good working condition – serviced and maintained regularly?
*
Yes
No
N/A
Other
Are all pre-start checks completed daily prior to operation of plant/machinery?
*
Yes
No
N/A
Other
Is all Plant operated safely (VOC's completed, safe speeds, rest breaks provided)?
*
Yes
No
N/A
Other
Are appropriate traffic controls in place for site, and is everyone abiding by them?
*
Yes
No
N/A
Other
Have all Hazardous Substances been identified and is training provided for safe use?
*
Yes
No
N/A
Other
Are you aware of the emergency evacuation procedure and response team on site?
*
Yes
No
N/A
Other
Do you have all of the appropriate PPE for your task(s)?
*
Yes
No
N/A
Other
Workplace Health
Are you required to undertake additional tasks outside of your job description?
*
Yes
No
N/A
Other
Are you aware of the procedure for reporting hazards at your current workplace?
*
Yes
No
N/A
Other
Are minimum rest-breaks provided (10mins rest + 30min lunch)?
*
Yes
No
N/A
Other
Are you able to keep up with your workload at a safe pace – without rushing?
*
Yes
No
N/A
Other
Are you provided with sufficient tools/equipment to undertake your tasks safely?
*
Yes
No
N/A
Other
Have you received adequate training and instruction for ALL tasks at this site?
*
Yes
No
N/A
Other
Do you receive adequate supervision for the tasks you undertake at this site?
*
Yes
No
N/A
Other
Have you experienced any conflicts between workers or supervisors at this site?
*
Yes
No
N/A
Other
Are you receiving support from your co-workers and supervisory personnel?
*
Yes
No
N/A
Other
Do you know who your site Health and Safety Representative is?
*
Yes
No
N/A
Other
Please provide the name of your Health and Safety Representative:
*
Do you have any safety concerns towards this workplace or their work processes?
*
Yes
No
N/A
Other
Workplace Hygeine
Are all commonly touched surfaces (common areas) cleaned and maintained regularly?
*
Yes
No
N/A
Other
Are sufficient amenities available for all workers (hand-soap/sanitizer/paper-towel, toilet paper)?
*
Yes
No
N/A
Other
Are you able to maintain a distance of 1.5 meters between other persons on site?
*
Yes
No
N/A
Other
Have any persons on site been suspected of carrying, or confirmed to have contracted COVID-19?
*
Yes
No
N/A
Other
Have you recently experienced a fever, sore throat, dry-cough, fatigue or shortness of breath?
*
Yes
No
N/A
Other
NOTES
Please sign:
*
Submit
Should be Empty: