[Note to employers: This survey can be used to gauge employee sentiment around returning to the workplace during the coronavirus outbreak and to understand where their pain points are. It can be modified to include specific concerns to your workplace. This survey information can help determine where more communication or training is needed to help employees feel safer in the workplace.]
As [Company name] begins to welcome our employees back to the workplace, we'd like to better understand your thoughts and concerns surrounding the COVID-19 pandemic and [Company name]'s efforts to keep you safe.
We would appreciate it if you would take the time to complete this anonymous survey by [enter date]. If you would like a personal response to your individual comments, please enter your name and department at the end of the survey, and a representative from HR will contact you directly.
Using a scale of 1-5, with 5 being strongly agree and 1 being strongly disagree, please select one response for each statement.
| | | | | | |
|---|---|---|---|---|---|
| General Questions | 5 | 4 | 3 | 2 | 1 |
| I feel confident [Company name] leadership can bring me back to work safely. | ° | ° | ° | ° | ° |
| I believe appropriate safety protocols will be in place when I return to work. | ° | ° | ° | ° | ° |
| I understand the safety protocols being implemented to prevent COVID-19 infections at work. | ° | ° | ° | ° | ° |
| I understand the importance of screening employees for symptoms of COVID-19. | ° | ° | ° | ° | ° |
| I have no fear of being infected with the coronavirus while at work because of my own health conditions. | ° | ° | ° | ° | ° |
| I have no fear that I will carry the virus home to family members and infect them. | ° | ° | ° | ° | ° |
| I have no fear of contracting the virus from co-workers. | ° | ° | ° | ° | ° |
| I have no fear of contracting the virus from customers. | ° | ° | ° | ° | ° |
| I believe my job would be negatively impacted if I tested positive for COVID-19. | ° | ° | ° | ° | ° |
| I feel safe traveling to and from work. | ° | ° | ° | ° | ° |
| I feel I will have adequate access to child care. | ° | ° | ° | ° | ° |
| I feel safe traveling for business reasons. | ° | ° | ° | ° | ° |
| I feel confident about my job security. | ° | ° | ° | ° | ° |
| I feel confident about the financial stability of [Company name]. | ° | ° | ° | ° | ° |
| [Add others relevant to your workplace] | ° | ° | ° | ° | ° |
| | | | |
|---|---|---|---|
| Which safety measures do you want to see in the workplace? | Yes | No | Unsure |
| Required masks | ° | ° | ° |
| Optional masks | ° | ° | ° |
| Face shields | ° | ° | ° |
| Employer-provided masks or face shields | ° | ° | ° |
| Individual hand sanitizer | ° | ° | ° |
| Hand sanitizer stations | ° | ° | ° |
| Additional hand washing areas/stands | ° | ° | ° |
| Daily disinfection of work areas/common areas | ° | ° | ° |
| Physical-distancing protocols | ° | ° | ° |
| Staggered shifts/breaks/days in office | ° | ° | ° |
| Daily employee health screening | ° | ° | ° |
| Employer testing for COVID-19 | ° | ° | ° |
| Increased telecommuting | ° | ° | ° |
| Detailed protocols for handling workplace exposures | ° | ° | ° |
| Limited business travel | ° | ° | ° |
| Visitor health screening | ° | ° | ° |
| Not allowing visitors/clients in the workplace | ° | ° | ° |
| Plexiglass barriers between co-workers/customers | ° | ° | ° |
| [Add others relevant to your workplace] | ° | ° | ° |
Please add any comments or concerns you have below:
| |
Optional:
| Employee name: | Dept.: |
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