Screener Survey (OSHA)

OMB Number: 1225-0093
Exp. Date: 2/29/2024

Burden Statement

All responses to this survey are voluntary. The OMB Control Number for this survey is No. 1225-0093 (expires 02/29/2024), with an estimated burden time of 15 minutes. Please send comments about this survey to Madeline Martinez at Martinez.Madeline.M@dol.gov”

Please complete this screener survey for participants in OSHA’s Focus Group on the Experience of Special Government Employees (SGEs) in the Voluntary Protection Programs

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* 1. Name:

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* 2. Email:

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* 3. Please select type of employee (select all that apply)

Supervisor/Manager

Safety Professional

Health Professional

Other (please specify)

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* 4. How many years have you been in safety/health (please enter a number between 0-50):

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* 5. Please select type of specialization (select all that apply)

PSM- Level 1

Construction

Mobile Work Force VPP site

Ergonomics

CIH

Maritime

Other (please specify)

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* 6. Please select type of employer:

Department of Defense

Federal Employee

Department of Energy

Private sector

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* 7. Please select all the VPP activities that you’re responsible for at your worksite:

preparing the annual self-evaluation report for your worksite

mock audits

preparing for the VPP on-site evaluation at your worksite

communicating with OSHA staff

communicate with other SGEs at different worksites or companies about SGE or VPP activities.

Other (please specify)

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* 8. What qualifying activities outside of your VPP worksite have you participated on in the past 3 years (please select all that apply):

On-site audits

Mentoring VPP sites

Reviewing VPP applications

Instructing SGE courses

Review Annual Self-Evaluations

Other (please specify)

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* 9. How many SGE activities have you participated on in the past 3 years (please enter a number between 0 and 20):

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* 10. Are you interested in participating in a virtual SGE Focus Group Interview to describe your experience as an SGE? Saying yes now is not a commitment on your part. You are free to change your mind on participation.

Yes

Screener Survey (OSHA)OMB Number: 1225-0093 Exp. Date: 2/29/2024

Question Title

* 1. Name:

Question Title

* 2. Email:

Question Title

* 3. Please select type of employee (select all that apply)

Question Title

* 4. How many years have you been in safety/health (please enter a number between 0-50):

Question Title

* 5. Please select type of specialization (select all that apply)

Question Title

* 6. Please select type of employer:

Question Title

* 7. Please select all the VPP activities that you’re responsible for at your worksite:

Question Title

* 8. What qualifying activities outside of your VPP worksite have you participated on in the past 3 years (please select all that apply):

Question Title

* 9. How many SGE activities have you participated on in the past 3 years (please enter a number between 0 and 20):

Question Title

* 10. Are you interested in participating in a virtual SGE Focus Group Interview to describe your experience as an SGE? Saying yes now is not a commitment on your part. You are free to change your mind on participation.

Screener Survey (OSHA)

OMB Number: 1225-0093
Exp. Date: 2/29/2024