| Q No. | Question | Strongly disagree | disagree | Neither Agree nor Disagree | Agree | Strongly Agree |
| Management Commitment | ||||||
| X1 | Management acts decisively when a safety concern is raised |
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| X2 | Management acts only after accidents have occurred |
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| X3 | Corrective actions are always taken when management is told about unsafe practices |
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| X4 | In my workplace management acts quickly to correct safety problems |
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| X5 | In my workplace management turn a blind eye to safety issues |
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| X6 | In my workplace managers/supervisors show interest in my safety |
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| X7 | Managers and supervisors express concern if safety procedures are not adhered to |
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| Communication | ||||||
| X8 | Management operates an open door policy on safety issues |
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| X9 | My supervisor does not always inform me of current concerns and issues |
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| X10 | I do not receive praise for working safely |
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| X11 | Safety information is always brought to my attention by my line manager/supervisor |
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| X12 | There is good communication here about safety issues which affect me |
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| Priority of Safety | ||||||
| X13 | I believe that safety issues are not assigned a high priority |
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| X14 | Management clearly considers the safety of employees of great importance |
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| X15 | Safety rules and procedures are carefully followed |
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| X16 | Management considers safety to be equally as important as production Safety Rules and Procedures |
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| X17 | Sometimes it is necessary to depart from safety requirements for production’s sake |
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| X18 | Some health and safety rules and procedures are not really practical |
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| X19 | Some safety rules and procedures do not need to be followed to get the job done safely |
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| Supportive Environment | ||||||
| X20 | Employees are not encouraged to raise safety concerns |
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| X21 | Co-workers often give tips to each other on how to work safely |
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| X22 | I am strongly encouraged to report unsafe conditions |
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| X23 | When people ignore safety procedures here, I feel it is none of my business |
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| X24 | A no-blame approach is used to persuade people acting unsafely that their behavior is inappropriate |
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| X25 | I can influence health and safety performance here |
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| Involvement | ||||||
| X26 | I am involved in informing management of important safety issues |
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