CHI- Safety Locks & Procedures- May 2017

1. Demographic Section

Plaza Research Chicago is conducting a discussion with employees who work in Oil & Gas, Ship Building/Maritime, Refinery/Chemical Processing Plants, Food/Beverage Processing, Aerospace Defense, Hospitals/Healthcare, Utilities, Contractor Electrical and other types of Manufacturing. We are looking for Decision Makers who work at a company that utilizes padlock devices used for equipment safety lockout tagout purposes. The discussion takes place on Monday, May 24th, 2017 at Plaza Research. If you qualify and participate, you will receive $200 for 120 minutes. You will be required to bring examples of locks used at your company.

Please answer the questions below. If you look like a match, we will contact you by telephone.

**Due to the large response to our surveys, we are only able to contact those that look like a match. Please continue to answer future studies, as you may be a match to those.

Question Title

* 1. Please provide us with the following information. We will be contacting you by telephone if you seem like a match.

Name:

ZIP:

Email Address:

Phone Number:

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* 2. Alternate Contact number

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* 3. What is your Employment Status?

Please list the occupation, company and industry for all employed members of your household

CHI- Safety Locks & Procedures- May 2017

1. Demographic Section

Question Title

* 1. Please provide us with the following information. We will be contacting you by telephone if you seem like a match.

Question Title

* 2. Alternate Contact number

Question Title

* 3. What is your Employment Status?

Question Title

* 4. Are you male or female?

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* 5. What is your age?