PRODUCTION WORKERS: TAKE THE HEALTH AND SAFETY SURVEY

Too many of our coworkers have been hurt—or killed—at Cintas.  We can start making our jobs safer by answering the following questions and taking action in our plants.  All of the information provided below is confidential.

* required

First Name

Last Name

Email

Phone Number

Cell Number

Street Address

City *

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Zip *

Job Title

Department

Start Date (MM/DD/YYYY)

1. Is there dangerous moving equipment in your plant?
Yes No

2. Do you ever have to climb on or crawl under machines to unjam them?
Yes No

3. Do you ever have to go inside machines to clean them or unjam them?
Yes No

4. Is the equipment guarded to make sure no one can get caught in it?
Yes No

5. Do you or your coworkers ever work close to exposed moving machine parts?
Yes No

6. Do you have any injuries from making repetitive motions?
Yes No

7. Do you know of anyone who has suffered an injury or illness at work?
Yes No

8. What are the other safety or health issues in your plant?

This survey is confidential.  No individal information will be released without the specific written consent of the person indicated on the survey.