[Company Name] is seeking feedback from employees on the quality and types of benefits currently offered. Please answer as many questions as you can, basing your answers on personal experiences.
All responses are anonymous and confidential. Please complete the survey by [date]. Thank you in advance for your cooperation.
Answer each of the following questions by choosing the rating number you think is most appropriate. Feel free to make comments next to each statement or on the back of the survey.
Using a scale of 1-5, with 5 being very satisfied and 1 being very dissatisfied, please select one response for each statement. If you are not using the benefit, please choose N/A.
| Insurance Benefits | 5 | 4 | 3 | 2 | 1 |
| Health insurance | ° | ° | ° | ° | ° |
| Dental insurance | ° | ° | ° | ° | ° |
| Vision insurance | ° | ° | ° | ° | ° |
| Flexible spending account (FSA) | ° | ° | ° | ° | ° |
| Short-term disability insurance | ° | ° | ° | ° | ° |
| Long-term disability insurance | ° | ° | ° | ° | ° |
| Group life insurance | ° | ° | ° | ° | ° |
| Comments or suggestions for improvement: Using a scale of 1-5, with 5 being very satisfied and 1 being very dissatisfied, please select one response for each statement. If you are not using the benefit, please choose N/A. | |||||
| Paid Time Off | 5 | 4 | 3 | 2 | 1 |
| Paid sick leave | ° | ° | ° | ° | ° |
| Paid vacation | ° | ° | ° | ° | ° |
| Paid holidays | ° | ° | ° | ° | ° |
| Bereavement leave | ° | ° | ° | ° | ° |
| | | | | | |
| Comments or suggestions for improvement: | |||||
Using a scale of 1-5, with 5 being very satisfied and 1 being very dissatisfied, please select one response for each statement. If you are not using the benefit, please choose N/A.
| Other Benefits | 5 | 4 | 3 | 2 | 1 |
| 401(k) retirement plan | ° | ° | ° | ° | ° |
| Tuition reimbursement | ° | ° | ° | ° | ° |
| Wellness program | ° | ° | ° | ° | ° |
| ° | ° | ° | ° | ° | |
| ° | ° | ° | ° | ° | |
| Comments or suggestions for improvement: Using a scale of 1-5, with 5 being very satisfied and 1 being very dissatisfied, please select one response for each statement. If you are not using the benefit, please choose N/A. | |||||
What would you improve about the benefits offered by [Company Name]? Please provide comments about benefits that are currently offered and/or benefits that you would like to see offered.
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[If there are certain benefits the company is considering adopting it may be helpful to gauge employee interest before making the investment. Consider listing these benefits and asking employees to rank them or indicate which benefits are of interest.]
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