Safety - 360 Degree Feedback Survey Sample #10

360 Feedback Survey

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)

Thank you for providing feedback for the recipient above. As you respond, please draw on your first-hand experience with this individual in the past 12 months. Rate each item using the scale shown. If you don't feel you have enough first-hand information to rate a certain item, please choose the Not Applicable option. Comments can be very helpful; at a minimum where you give a particularly high or low rating, please share your reasons in the comment section for that competency. Your responses will be compiled with feedback from others and presented to the recipient to help guide their ongoing development.

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.


  • Develops a culture of safety.
  • Keeps accurate safety records.
  • Commits adequate resources toward safety measures.
  • Ensures that all supervisors are aware of regulatory and compliance measures.
  • Mitigates hazards and safety issues that arise.
If [Participant Name] were to make improvements in Safety, what are your suggestions for how he/she can improve this?

Customer Focus

  • Provides a responsive service that meets the needs of customers.
  • Effectively troubleshoots customer issues.
  • Builds trust with the customer.
  • Interacts with customers to define roles, expectations, and responsibilities.
  • Responds to the needs of the customer.
If [Participant Name] were to make improvements in Customer Focus, what are your suggestions for how he/she can improve this?

Strategic Insight

  • Formulates strategies and action plans to ensure successful completion of goals and objectives.
  • Formulates policies and strategies for addressing the Company's important challenges.
  • Communicates vision for the department and company.
  • Analyzes records and reports to obtain insight into potential issues and trends.
  • Understands the Company's strengths and weaknesses and uses this information to create optimal solutions to problems.
If [Participant Name] were to make improvements in Strategic Insight, what are your suggestions for how he/she can improve this?


  • Keeps supervisor informed of recent events.
  • Can be counted on to do what they say they are going to do.
  • Takes responsibility for results.
  • Holds team accountable to meeting goals.
  • Tackles issues head on and finds solutions.
If [Participant Name] were to make improvements in Accountability, what are your suggestions for how he/she can improve this?


  • Takes on extra projects after required work is completed.
  • Informs the manager of any important changes in the equipment operation.
  • Takes action without being asked.
  • Immediately works on solving problems.
  • Takes corrective action to address performance deficiencies/issues.
If [Participant Name] were to make improvements in Initiative, what are your suggestions for how he/she can improve this?
Overall, please rate the effectiveness of [Participant Name Here].


Areas for Development

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