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300-BXB-01-IGDO © 2025, Workplace Safety & Prevention Services (WSPS)
1 877 494 WSPS (9777) | 905 614 1400 | wsps.ca
Important Note to Users: This tool has been provided to you as a voluntary resource. If you decide to
use it, you understand that:
1. You may modify the questions in any way you wish,
2. You assume sole responsibility for its use, including any changes you make,
3. The information gathered by this tool is not required by the OHSA and should NOT be
submitted to the Ontario Ministry of Labour.
Efforts have been made to make it as easy as possible for you to adapt this tool to your unique circumstances. Throughout the
tool, we have included tips to help you decide whether to use the questions and how to interpret the results. This supplementary
advice is presented in green font throughout the questionnaire template. See Appendix A for a clean version of this questionnaire
Building Support for the Questionnaire
Discuss this questionnaire and its purpose with your management team first. You need to be
certain that your management team supports your commitment to this process. If you have
a Joint Health and Safety Committee (JHSC) or a Health and Safety Representative (HSR),
consider including them in your planning stages.
Once you have support of the management team, and JHSC/HSR if applicable, send a message to
all staff to let them know that a questionnaire will be done, why you are doing it, how the results
will be used and how confidentiality will be maintained.
Protecting Confidentiality
Ensuring confidentiality is essential when administering this questionnaire. Staff may be
concerned that they will be individually identified. You are in the best position to assess how to
protect confidentiality based on the profile of your workforce and the physical environment of
your workplace.
Consider how you will administer the questionnaire. Some staff may be more comfortable with
a paper-based questionnaire that requires only check marks (i.e. no identifiable handwriting),
as long as the paper can be deposited discreetly into a securely sealed box. Others may prefer
an online questionnaire that can be completed away from the workplace. Whatever method you
choose, either electronic or paper-based, staff must feel they can complete the questionnaire
without fear of identification or penalty.
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