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Custom Questions (optional)
Question type (open-ended, multiple choice, check
all that apply) Include answer options if applicable.
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3. Primary Contact (Who will we work with on your campus to deploy this survey):
a. Name:
b. Email:
c. Phone:
4. Survey start/end dates (Recommend 2-weeks. We will send 1-reminder after one week and a final
reminder 2 days before the survey closes).
a. Start date:
b. End date:
Environmental Health/Occupational Safety Programs
(EHOS)
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Return survey to: anaiknimbalkar@calstate.edu
1.
Which of the following programs are you familiar with or involved with on campus? (Check all that
apply.)
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Biological Safety
Environmental compliance
Ergonomics
Fire life safety and fire prevention
Hazard assessments
Hazard communication
Hazardous materials and waste management
Indoor air quality
Industrial hygiene
Injury and illness prevention
Laboratory safety
Radiation safety
Safety training
Other
(please describe Other below)
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Service from Program Staff
2.
Thinking of your OVERALL experience with our programs over the past 12 months, please rate how
strongly you agree or disagree with the following statements. If you cannot rate the item, or it's not
applicable, select "Don't Know/ NA."
Program staff respond in a timely
manner to my requests or problems
Program staff are courteous and helpful
Program staff understand my or my
department's occupational safety needs
and requirements
Program staff are willing to solve
problems
Program staff are knowledgeable and
professional
Program staff and the information they
provide are credible
Program staff provide effective advice,
support, and guidance
Additional comments:
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
Don't Know /
NA
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Injury & Illness Prevention Program (IIPP)
The IIPP program is designed to manage the working and educational
environments to identify and minimize hazards and prevent unsafe
conditions.
3.
Have you had any experience with this program in the past 12 months?
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Yes
No
I'm not sure
Injury & Illness Prevention Program (IIPP)
The IIPP is used to manage the working and educational environments to
identify and minimize hazards and prevent unsafe conditions. The IIPP is
the overall program for ensuring that employees have a safe and healthy
working environment. All other campus safety programs are governed by
the principles of the IIPP.
4.
Thinking of your experience with the IIPP over the past 12 months, please rate how strongly you agree
or disagree with the following statements. If you cannot rate the item, or it's not applicable, select "Don't
Know / NA."
The IIPP is easily accessible in
hardcopy or electronic format
Prior to taking this survey I understood
the intent of the IIPP
Information provided about the IIPP is
clear and concise
Training I received regarding the
campus IIPP was clear and concise
Additional comments:
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
Don't Know /
NA
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Ergonomics: Workstation Evaluation or Equipment Recommendation
Program
Ergonomics is the design of tasks, work spaces, controls, displays, tools,
lighting and equipment to fit the employee's physical capabilities and
limitations.
5.
Have you had an ergonomic evaluation in the past 12 months?
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Yes
No
I'm not sure
Ergonomics: Workstation Evaluation or Equipment Recommendation
Program
6.
Thinking of your experience with the Ergonomics Program over the past 12 months, please rate how
strongly you agree or disagree with the following statements. If you cannot rate the item, or it's not
applicable, select "Don't Know / NA."
I understand the process to initiate an
ergonomic evaluation
The information provided by the
ergonomic evaluation was clear and
concise
The outcome of the ergonomic
evaluation was an improved
workstation
Additional comments:
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
Don't Know /
NA
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Fire Life Safety: Fire Prevention Program, Inspections and Building
Evacuation
7.
Have you had any experience with fire prevention, inspections and evacuations in the past 12 months?
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Yes
No
I'm not sure
Return survey to: anaiknimbalkar@calstate.edu
Fire Life Safety: Fire Prevention Program, Inspections and Building
Evacuation
8.
Thinking of your experience with fire prevention, inspections and evacuations in the past 12 months,
please rate how strongly you agree or disagree with the following statements. If you cannot rate the
item, or it's not applicable, select "Don't Know / NA."
Information on emergency response
and evacuation procedures is readily
available
Evacuation drills are conducted safely
and in an orderly manner
The reporting of building fire and life
safety concerns is easy and
understandable
Additional comments:
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
Don't Know /
NA
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Hazardous Materials: Safe Chemical Use and Storage
9.
Have you had experience with hazardous materials in the past 12 months?
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Yes
No
I'm not sure
Hazardous Materials: Safe Chemical Use and Storage
10.
Thinking of your experience with hazardous materials over the past 12 months, please rate how strongly
you agree or disagree with the following statements. If you cannot rate the item, or it's not applicable,
select "Don't Know / NA."
The Chemical and Laboratory Safety
Programs are readily accessible
The use and storage of hazardous
materials are done in a safe and
healthful manner in my area
The information and direction provided
by the Office that manages this
program was clear and concise
Additional comments:
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
Don't Know /
NA
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Hazard Communication: Material Safety Data Sheet [MSDS] Access /
Use, Chemical Signage and Labeling
11.
Have you had any experience with material safety data sheets, chemical signage, and labeling in the
past 12 months?
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Yes
No
I'm not sure
Hazard Communication: Material Safety Data Sheet [MSDS] Access /
Use, Chemical Signage and Labeling
12.
Thinking of your experience with the Hazard Communication Program (MSDSs, chemical signage and
labeling) over the past 12 months, please rate how strongly you agree or disagree with the following
statements. If you cannot rate the item, or it's not applicable, select "Don't Know / NA."
The location of chemical Material
Safety Data Sheets is known (hardcopy
or electronic)
I understand the purpose of an MSDS
The hazard signage for chemicals in
the workplace is appropriate and
understandable
The information provided by the Office
that manages this program is clear and
concise
Additional comments:
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
Don't Know /
NA
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Environmental Health/Occupational Safety training additional
comments:
13.
Have you attended any safety training classes or received individual safety training in the past 12
months?
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Yes
No
I'm not sure
Return survey to: anaiknimbalkar@calstate.edu
Environmental Health/Occupational Safety training additional
comments:
14.
Thinking of your experience with the safety training you received in the past 12 months, please rate how
strongly you agree or disagree with the following statements. If you cannot rate the item, or it's not
applicable, select "Don't Know / NA."
The representative was courteous
The course content was relevant
The training was understandable
The presentation was professional and
informative
The training was beneficial in improving
my workplace safety
15.
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
Don't Know /
NA
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Do you prefer classroom or electronic training for environmental health and occupational safety?
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Classroom
Electronic
Both
Additional comments:
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Communicating Safety Information
16.
How willing are you to use the following methods to communicate with Environmental
Health/Occupational Safety?
Website
Phone
Email
In person
Intercampus mail
Not at all likely to
use
Might use
Likely to use
Very likely to use
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Please tell us any suggestions you have regarding how to effectively communicate safety information to you.
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Website for Environmental Health/Occupational Safety Programs
17.
Have you visited the website of the office that manages the University's Environmental
Health/Occupational Safety Program in the past 12 months?
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Yes
No
Return survey to: anaiknimbalkar@calstate.edu
Website for Environmental Health/Occupational Safety Programs
18.
In the past year how often did you visit the Environmental Health/Occupational Safety website?
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Occasionally - 3 to 5 times
Often - 6 or more times
When you visited the website, how easy was it for you to find what you were looking for?
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Rarely - only 1 or 2 times over the year
Very difficult - I usually have not found what I'm looking for
Somewhat difficult - I sometimes have difficulty finding what I'm looking for
Somewhat easy - I often find what I'm looking for
Very Easy- I always find what I'm looking for
Please rate how strongly you agree or disagree with the following statement:
The website met my information needs.
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Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
If the website did not meet your information needs, please take a moment to explain.
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Additional comments:
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Hazard Reporting: Reporting safety issues or complaints
21.
Have you had any experience reporting a hazard or having an employee report a hazard in the past 12
months?
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Yes
No
I'm not sure
Return survey to: anaiknimbalkar@calstate.edu
Hazard Reporting: Reporting safety issues or complaints
22.
Thinking of your experience reporting a hazard or having an employee report a hazard in the past 12
months, please rate how strongly you agree or disagree with the following statements. If you cannot
rate the item, or it's not applicable, select "Don't Know / NA."
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
Don't Know /
NA
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The process for reporting on-campus
safety hazards is clear
The on-line hazard reporting form is
readily accessible
The office that manages Hazard
Reporting was helpful in dealing with
my concern
The reporting of the hazard resulted in
a safer work site
Additional comments:
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Hazard Reporting: Reporting safety issues or complaints
23.
You responded "No" to the question "Have you had any experience reporting a hazard or having an
employee report a hazard in the past 12 months?" Please take a moment and indicate why not. (Check
all that apply.)
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I do not know of any hazards to report
I know of a hazard but I did not know how to report it
I know of a hazard but I have not had time to report it
I know of a hazard but I did not believe it would do any good
Other
(please describe Other below)
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24.
What sorts of things can we do to make the Hazard Reporting process more useful or easy to access?
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Hazard Reporting: Reporting safety issues or complaints
25.
Are you aware of any safety concerns or hazards that you think should be reported?
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Yes, definitely
Possibly
No
I don't know
If Yes or Possibly, please take a moment to describe the types of safety concerns or hazards that you have observed.
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26.
Would you like a representative of the office that manages Environmental Health/Occupational Safety to
contact you regarding these safety concerns or hazards?
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Yes
No
Name
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Email
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Phone
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Optional: For reference, use the space below to list a title or brief description of the issue you want to be contacted about.
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27.
Classification:
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28.
Faculty
Staff
MPP
Division affiliation:
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_________________________________
29.
Campus_Name
Return survey to: anaiknimbalkar@calstate.edu
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