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Safety - 360 Degree Feedback Survey Sample #2





Questionnaires Measuring Safety:
Survey 1 (4-point scale; Competency Comments)
Survey 2 (4-point scale; Competency Comments)
Survey 3 (5-point scale; Competency Comments)
Survey 4 (5-point scale; radio buttons)
Survey 5 (4-point scale; words)
Survey 6 (4-point scale; words)
Survey 7 (5-point scale; competency comments; N/A)
Survey 8 (3-point scale; Agree/Disagree words; N/A)
Survey 9 (3-point scale; Strength/Development; N/A)
Survey 10 (Comment boxes only)
Survey 11 (Single rating per competency)
Survey 12 (Slide-bar scale)
Survey 13 (4-point scale; numbers; floating anchors)
Survey 14 (4-point scale; N/A)
Instructions

You have been selected to provide feedback on the employee listed above. Your feedback is an important part of our company's leadership development process and this survey is intended to gather broad feedback in the core competencies and role responsibilities that are important for the on-going success of our organization.

In responding to the questions below, think about your experiences working with this employee over the last twelve months and the goals they were asked to achieve. The effectiveness of this development tool is dependent on your honest, forthright and constructive responses so please bear this in mind as you answer each question. Your responses will be discussed with the employee to foster growth and on-going development.

Competencies Included:
Safety, Continual Learning, Attitude, Establishing Focus/Direction, Persuasion and Influence, Problem Solving, Juggling Multiple Responsibilities, Commitment, Clarity, Client Focus, Company
Sample Result Document:
Sample Results
Partially completed forms can be saved by using the Save/Still Working button at the bottom of the page. You may return at a later time to complete/edit the form. Your saved responses will be shown each time you re-visit the feedback form. When you are certain that you have completed your responses and will be not making any changes, click the Complete button.

Please ensure that your submission is made between . The survey will only be available during these dates.
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Safety

Clear
Strength
Capable
and
Effective
Could
Benefit from
Development
Needs
Significant
Improvement
  1. Conducts audits to ensure compliance with safety standards and regulations.
  1. Keeps accurate safety records.
  1. Ensures employees have a clean work environment.
  1. Prepares disaster recovery plans and procedures.
  1. Recognizes teams or individuals who contribute to hazard reduction.
What are your suggestions for how [Participant Name] can make improvements
in Safety?

Continual Learning

Clear
Strength
Capable
and
Effective
Could
Benefit from
Development
Needs
Significant
Improvement
  1. Takes the initiative to learn new skills.
  1. Views setbacks as opportunities to learn from.
  1. Pursues learning that will enhance job performance.
  1. Takes charge of their training and skills enhancement.
  1. Builds on their strengths while addressing their weaknesses.
What are your suggestions for how [Participant Name] can make improvements
in Continual Learning?

Attitude

Clear
Strength
Capable
and
Effective
Could
Benefit from
Development
Needs
Significant
Improvement
  1. Always does their best effort on the job.
  1. Shows by their actions that they trust in the positive intentions of others.
  1. Offers constructive criticism.
  1. Shows genuine interest in the well-being of colleagues, beyond work performance.
  1. Expresses genuine belief in the team's ability to overcome challenges and thrive.
What are your suggestions for how [Participant Name] can make improvements
in Attitude?

Establishing Focus/Direction

Clear
Strength
Capable
and
Effective
Could
Benefit from
Development
Needs
Significant
Improvement
  1. Establishes guidelines and procedures to ensure workplace safety and compliance with regulations.
  1. Stays focused even when under pressure and stress.
  1. Outlines specific behaviors and outcomes that constitute success in the role.
  1. Seeks to enhance their understanding of the department's dynamics to better determine the needs of the department.
  1. Identifies early signs of misalignment and intervenes to restore focus and direction.
What are your suggestions for how [Participant Name] can make improvements
in Establishing Focus/Direction?

Persuasion and Influence

Clear
Strength
Capable
and
Effective
Could
Benefit from
Development
Needs
Significant
Improvement
  1. Develops a good rapport with others.
  1. Uses real-life examples to foster understanding and encourage thoughtful action.
  1. Overcomes employees' resistance to change and action.
  1. Builds trust by framing negotiations around shared goals and mutual value, not just positional wins.
  1. Demonstrates deep subject matter knowledge through clear, confident explanations that build trust.
What are your suggestions for how [Participant Name] can make improvements
in Persuasion and Influence?

Problem Solving

Clear
Strength
Capable
and
Effective
Could
Benefit from
Development
Needs
Significant
Improvement
  1. Able to solve problems with multiple criteria that need to be met.
  1. Implements solutions to solve the problem.
  1. Creates a table or chart to compare the solutions side-by-side across all evaluation criteria.
  1. Conducts a cost-benefit analysis for each solution to determine its financial viability and potential return on investment.
  1. Determines what needs fixed, its root causes, and the correct solutions to be implemented.
What are your suggestions for how [Participant Name] can make improvements
in Problem Solving?

Juggling Multiple Responsibilities

Clear
Strength
Capable
and
Effective
Could
Benefit from
Development
Needs
Significant
Improvement
  1. Ensures that assignments are prioritized according to the needs of the department/company.
  1. Identifies which tasks require direct attention and which can be delegated to others without loss of quality.
  1. Uses structured routines or mental models to stay grounded during chaotic or ambiguous situations.
  1. Finds creative workarounds when tools, people, or processes are unavailable or delayed.
  1. Demonstrates minimal ramp-up time when returning to a previously interrupted task.
What are your suggestions for how [Participant Name] can make improvements
in Juggling Multiple Responsibilities?

Commitment

Clear
Strength
Capable
and
Effective
Could
Benefit from
Development
Needs
Significant
Improvement
  1. Aligns personal talents with organizational needs through strengthened commitment.
  1. Invites team members to make explicit commitments that can be tracked and revisited.
  1. Has personal values that are aligned with organizational values.
  1. Mobilizes commitment to create clear expectations and follow-through, turning promises into measurable action.
  1. Develops a culture of responsibility and follow-through.
What are your suggestions for how [Participant Name] can make improvements
in Commitment?

Clarity

Clear
Strength
Capable
and
Effective
Could
Benefit from
Development
Needs
Significant
Improvement
  1. Is clear about goals that need to be achieved.
  1. Clearly explains responsibilities to individuals.
  1. Clarifies problems and their causes to help employees correct them.
  1. Checks details thoroughly.
  1. Attends to the important details of a job or task.
What are your suggestions for how [Participant Name] can make improvements
in Clarity?

Client Focus

Clear
Strength
Capable
and
Effective
Could
Benefit from
Development
Needs
Significant
Improvement
  1. Is competent in handling difficult clients.
  1. Adapts to changing client needs.
  1. Their activities reflect a strong focus on the client relationship.
  1. Helps clients feel they are receiving services tailored specifically to their needs.
  1. Prioritizes client issues to tackle the most pressing needs first.
What are your suggestions for how [Participant Name] can make improvements
in Client Focus?

Company

Clear
Strength
Capable
and
Effective
Could
Benefit from
Development
Needs
Significant
Improvement
  1. Builds belief in the company's resilience and capacity to lead in its industry.
  1. Helps employee satisfaction by reminding employees of how their work contributes to the shared goals and long-term success of the company.
  1. Promotes CompanyName as a high quality company.
  1. Keeps the parking area well maintained.
  1. Drives innovation and excellence to keep the company's offerings competitive and compelling.
What are your suggestions for how [Participant Name] can make improvements
in Company?


  1. Strengths


  2. Areas for Development


  3. Please give any final comments or suggestions for [Participant Name Here]'s assessment.