North Dakota Work Site Safety Program Manual -- Page 6

SAMPLE EMPLOYEE PERCEPTION SURVEY

Date Conducted: _____________

1. If you are a passenger in a vehicle, you do not need to wear your safety belt.

2. You don't need to wear a safety belt, if you are riding in the back seat of a vehicle.

3. When I drive a vehicle on company business, I always wear my safety belt.

4. Other employees at my company do not take traffic safety seriously.

5. I have seen employees on company business driving over the speed limit.

6. Its okay to drive home after having three or four alcoholic beverages after work.

7. If I see a fellow employee who is noticeably intoxicated and attempting to drive, I would take his/her keys and arrange another way home for him/her.

8. Whenever I am using a vehicle for company business, I insist all passengers wear their safety belt.

9. My company strictly enforces the policy/policies relating to traffic safety.

10. I have observed employees on company business reading while driving.

Comments:

SAMPLE ACTIVITIES DEVELOPMENT WORKSHEET

Purpose: Copy this form and use it to develop your safety education activities. Review your "safety calendar" developed by your team for promotions and events to pursue. When the team chooses an activity, use this form as much as possible. Refer to it as the activity date approaches to check on whether the designated tasks are complete and on schedule.

Development:

1. Activity/event:

2. Date:

3. Describe activity/event:

4. Resources needed:

5. List team members who have agreed to help:

6. List team member responsibilities:

7. Evaluation/comments:

8. Timeline:

SAMPLE ACTIVITIES ASSESSMENT WORKSHEET

Purpose: Use this form to critique the activities coordinated by your work site safety program team.

Activity:

Time frame:

Description:

Goals (measurable):

Estimate number of employees reached:

Planning (what was/was not helpful):

Promotion (what worked/what did not):

Implementation (what worked/what did not):

Recommended improvements (for future activities):

EMPLOYER CRASH COST WORKSHEET

HOW DO YOU COMPARE? Fill in the table below using numbers reflecting your costs.
Lost market productivity
Lost household productivity
Property damage
Medical expenses
Travel delay
Total economic cost of motor vehicle crash