Cleaning Services Employee Health Survey

Please take a few minutes to complete this Employee Health Survey. Fill out all sections of the survey accurately. For items requiring a response, select the appropriate option or provide the necessary information. Your responses will remain confidential and will only be used for the purpose of assessing and improving workplace health and safety.

Personal Information

Field	Information
Name:
Department:
Date of Birth:
Employment Status:	Full-time Part-time Contractor

Health History

Question	Response
Have you experienced any recent illnesses?	Yes (pls. specify): No
Do you have any chronic health conditions?	Yes (pls. specify): No
Are you currently taking any medications?	Yes (pls. specify): No

Workplace Environment

Question	Response
Do you feel safe in your work environment?	Yes No (pls. specify):
Are you provided with necessary safety equipment?	Yes No (pls. specify):
Are there any areas of concern regarding workplace safety?	Yes (pls. specify): No

General Well-being

Question	Response
Do you feel stressed at work?
How would you rate your stress level?	Low Moderate High
Are you satisfied with your work-life balance?	Yes No
How would you rate your overall well-being?	Poor Fair Good Very Good Excellent
Any additional comments or concerns?

If you have any issues or concerns, don't hesitate to contact [Your Company Email] or call [Your Company Number].