Name: ______________________ Date _______________________

Address: _____________________________________________________
Department: _________________ Designation: _________________
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Please answer the questions correctly: All information is confidential
What do you know about healthy environment?
_______________________________________________________________________
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Is there any health condition that affects your ability to work?
YES NO
If yes, then what do you think is it due to your occupation?
YES NO
Do you have any hearing problem?
YES NO
Do you have any eye related problems?
YES NO
Do you wear spectacles or any other safety dress?
_______________________________________________________________________
_
Which activities you have to perform on duty?
_______________________________________________________________________
_
Is there any health issue related to it?
YES NO
Have you ever been injured at work?
YES NO
If yes, describe the cause of your injury
Which type of equipment you are using to avoid this particular risk?

Is there a department that deals with risk management?

YES NO
Are complaints registered and filed?
YES NO
Is there any mechanism to deal with waste and by-products?

Where it is disposed off in;

Landfill
Near by water body
Air
What is your opinion is it safe?
Are audit processes routinely carried out?
Is the environment conducive/ favorable to communicate with management?

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Are audit processes routinely carried out?