Quarterly Employee Status & Wellness Review "*" indicates required fields Step 1 of 9 - General 11% URLThis field is for validation purposes and should be left unchanged.Instructions: Please fill out every question. If not applicable, enter n/a.Name* First Last Location* Do you receive Medical Insurance?* Yes No Do you have any questions concerning your coverage?* Yes No Please Explain*Are you signed up for a 401K plan?* Yes No Do you have any questions concerning your benefits?* Yes No Please Explain* Do you have any questions concerning your employee handbook?* Yes No Please Explain* Do you understand the duties of your job?* Yes No Are you satisfied with your supervisor?* Yes No Do you feel you were adequately trained for your position?* Yes No Do you have any complaints or suggestions for improvement regarding management?* Yes No Please Explain* Do you have any ideas on how to improve safety, efficiency of operating, control costs, and/or improve profits?* Yes No Please Explain* Are you satisfied that you are safe in your working environment?* Yes No Are you aware of any areas that are unsafe and need improvement?* Yes No Please Explain Are you suffering from any pain as a result of an injury NOT related to your current employer?* Yes No Are you receiving any therapy or medical treatment related to the injury?* Yes No In the past year, have you been involved in a work related injury?* Yes No Please Explain*Are you suffering from any pain or other aggravation as a result of of an injury related to your current employer?* Yes No Are you receiving any therapy or medical treatment as a result of such accidents/injuries?* Yes No Please expound on what pain or aggravation you are experiencing / original incident / compounding factors, etc.* Do you still possess a valid driver's license?* Yes No Have there been any changes in the validity or status of your driver's license since the date of your employment?* Yes No Please Explain* Do you have any other comments or questions?* Yes No Please Explain*Date* Month Day Year Signature* Δ
