Job title or task:
Date:
Completed by:
MSD Hazard control/improvement:
This survey is being used to collect your opinions of the recent changes/improvements that have been made for your job/workstation. Please let us know what you think about the effectiveness, advantages and disadvantages of this change and provide any suggestions you might have for further improvement.
Picture or description of change/improvement:
1. Have you used this control/improvement?
a) No, haven't seen it
b) No, have seen it, but not used it
c) Yes, once or twice
d) Yes, a few times
e) Yes, regularly
2. If you answered yes, how would you rate this control/improvement?
| Dislike it - worse than before! | No different than before | Love it - huge improvement! | ||
|---|---|---|---|---|
1 | 2 | 3 | 4 | 5 |
3. What are some advantages of this control/improvement?
4. What are some disadvantages of this control/improvement?
5. Do you have any suggestions for this control/improvement?
Modified from Part3A: MSD Prevention Toolbox – Getting Started Developed by Occupation Health and Safety Council of Ontario (OHSCO)