© JMJ Associates, LLC All Rights Reserved

INCIDENT AND INJURY-FREE AS A VALUE Self Assessment

My Relationship to Safety

Instructions: Circle the answer that is most accurate for you

1. When driving, do I drive safely and within the speed limit? 1= always; 2= most of the time; 3= not when I am behind or in a hurry 2. When driving, do I talk on a cell phone, eat food or “fiddle” with the music system? 1= never; 2= occasionally; 3= lots of the time or when something is

really important 3. When I do work around my house do I wear a full range of appropriate PPE

(glasses, hearing protection, steel-toed shoes and hat)? 1= always; 2= most of the time; 3= almost never, especially when I am in

a hurry 4. Do I read the safety precautions for any new home appliances or equipment that I

buy? 1= always; 2= most of the time; 3= almost never, especially when I am

excited about playing with my new toy! 5. When I use a stepladder, do I use it properly and not step on the top step? 1= always; 2= most of the time; 3= almost never, especially when I am in

a hurry 6. When do I thoroughly review procedures, permits or JSA’s?

1= always; 2= occasionally; 3=hardly ever 7. When I see something that another person is doing that seems unsafe, do I stop

the person and express my concern? 1= always; 2= occasionally; 3= hardly ever 8. When I am reviewing my assignments (shift change, pre-job briefs, special

instructions or procedures, start-up/shutdown, etc.) and I do not understand the task, or I do not understand all of the dangers, do I speak up?

1= always; 2= occasionally; 3= hardly ever

Now, please add up your scores: TOTAL SCORE

(Turn the page over for your score)

JMJ

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© JMJ Associates, LLC All Rights Reserved

My Relationship to Safety:

If you scored 8 to 10 points, you have an extraordinary relationship to Safety

If you scored 11 to 19 points, you have an ordinary relationship to Safety

If you scored 20 to 24 points, you have an insufficient relationship to Safety (It is not going to happen to me!)