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* 1. What is your title?

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* 2. How long have you worked in the environmental, health and safety (EHS) field or had safety responsibilities?

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* 3. What is your current salary?

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* 4. Which of the areas do you have responsibility for? (Check all that apply)

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* 5. What is your educational background? (Choose highest attained)

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* 6. Check any of the certifications you currently hold:

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* 7. Describe your work environment:

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* 8. How many EHS professional events did you attend last year? (Check one)

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* 9. How would you describe the occupational safety and health program in your facility/organization?

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* 10. Would you say your organization’s safety performance in the last year has: (Check one)

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* 11. Does top management in your organization provide active and visible support for occupational safety and health?

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* 12. Is safety on par with production in your organization?

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* 13. Do you use leading indicators to measure safety performance?

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* 14. If you answered “yes” to Question 13, please check all that apply:

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* 15. Compared to the previous year, did the budget for occupational safety and health in your organization in 2012:

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* 16. Does your organization/facility have or make use of the following: (Check all that apply)

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* 17. Does your organization offer any of the following wellness offerings or initiatives? (Check all that apply)

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* 18. Have you ever witnessed or been directly impacted by workplace violence?

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* 19. If you answered “yes” to Question 18, please describe:

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* 20. Have you ever witnessed or been directly impacted by workplace bullying?

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* 21. If you answered “yes” to Question 20, please describe:

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* 22. Do you regularly follow the news, updates, regulatory decisions, announcements and/or publications from any of the following agencies? (Check all that apply)

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* 23. How would you rate David Michaels’ performance as OSHA administrator?

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* 24. You have been tasked to lead OSHA and have the ability to make any changes to the agency or its standards that you choose. What’s your first move?

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* 25. In what area would you most like to see improvement in your organization/facility’s safety and health program?

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* 26. What is the most frequent complaint you hear from employees about your organization’s safety and health program?

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* 27. What is the most common type of injury or illness you see within your organization?

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* 28. Can you share an example of a workplace EHS-related challenge your company solved or improved in the last year?

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* 29. May we contact you for more information for our feature report on the National Safety Survey?

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* 30. If you answered “yes” to the above question, please provide your contact information below:

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