2 Safe and Sound Week Event Feedback Form

2019 Safe + Sound Week Event Feedback Form

1. Name of Business or Organization* (Fill in Blank)

2. Industry* (Drop Down)

3. Email Address* (Fill in Blank)

4. Did you participate in the U.S.?* (Check box)

• Yes

• No

5. City/State (Fill in Blank and Drop Down)

6. City/Country (Fill in Blank)

7. How did you find out about the event?* (Check all that apply) (Check box)

• Communication from industry/trade association

• Communication from safety and health professional organization

• OSHA QuickTakes

• OSHA Website

• Safe + Sound Campaign Email List Serv

• National/Local/Trade Press

• Social Media

• Colleague

• I don’t know/remember

• Other (Fill in Blank)

8. Number of workers reached during your Safe + Sound Week event* (Fill in Blank)

9. What was your primary motivation for participating in Safe + Sound Week? (Check box – select one)

   • Celebrate meeting safety and health goal(s)

   • Engage workers in thinking about safety and health (e.g., get feedback, provide training, provide recognition, teambuilding)

   • Launch a new safety and health activity/initiative

   • Improve my organization’s safety and health performance

   • Respond to a specific safety and health issue within my workplace

   • Show leadership in our industry on safety and health

   • Other (fill in blank)

10. Participating in Safe + Sound Week had a positive impact on safety & health in my organization.

Strongly Disagree 1 2 3 4 5 NA Strongly Agree

(Check box)

Comments: (Fill in Blank)

11. Would you recommend participating in Safe + Sound Week to others? Why or why not? (Check box – select one)

    • Yes

    • No

Comments (Fill in Blank)

12. What did you like most about S+S Week? (Fill in Blank)

13. Is there anything else you would like to share? (Fill in Blank)

14. To help us better understand how participants used resources and what would be helpful in the future, Safe + Sound may wish to reach out to you for more information on your experience. Are you interested in sharing more about your experience?

• Yes

• No

If yes, please provide contact information:

Contact Name (Fill in Blank)

Contact Phone Number (Fill in Blank)

OMB Control Number 1218-0269

Expiration date: 05/31/2021

PAPERWORK REDUCTION ACT

Public reporting burden for this voluntary collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. OSHA will use this information to evaluate participation in Safe + Sound Week. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, please send them to OSHAPRA@dol.gov or to US Department of Labor, OSHA Directorate of Standards and Guidance N-3609, 200 Constitution Avenue, NW, Washington, DC 20210.

Requirements for the form:

• Question 1, 2, 3, 4, 7, 8 required for all responses.

• The following selection would be optional following question 1:

I want my business or organization to be added to the public Safe + Sound Week map on the website. (Check box)

• Industry drop down should include the following:

Agriculture, Forestry, Fishing and Hunting

Construction

Government

Health Care and Social Assistance

Manufacturing

Maritime

Oil and Gas

Professional and Business Services

Transportation and Warehousing

Utilities

Other: ___________________________________ (Fill in Blank)

• Question 5 required if answer “yes” to Question 4.

• Question 6 required if answer “no” to question 4.

• In Question 5, the “State” field will be a drop-down menu with full state and territory names.

• If Question 14 answered “yes”, contact name and contact phone number required.