March 2021

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* 1. Name:

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* 2. Email:

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* 3. Mobile:

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* 4. Centre Location:

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* 5. Employment Status:

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* 6. Do you know who your Health and Safety Representative (HSR) is?

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* 7. Are you interested in stepping up or obtaining some further information regarding the HSR role?

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* 8. Do you know how to report an incident/near miss at work via the safety Max system?

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* 9. What are the main areas of concern for you at work?

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* 10. Do you feel heard/listened to at work with your concerns?

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* 11. Do you feel safe to raise issues?

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* 12. Are you interested in stepping up into a delegates position?

Thank you for taking the time to complete this survey.

Authorised by Lisa Darmanin, Branch Secretary, ASU Victorian and Tasmanian Authorities and Services Branch, 116 Queensberry Street, Carlton South, 3053

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