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Members may download one copy of our sample forms and templates for your personal use within your organization. Please note that all such forms and policies should be reviewed by your legal counsel for compliance with applicable law, and should be modified to suit your organization’s culture, industry, and practices. Neither members nor non-members may reproduce such samples in any other way (e.g., to republish in a book or use for a commercial purpose) without SHRM’s permission. To request permission for specific items, click on the “reuse permissions” button on the page where you find the item.
To improve Company Benefit Package, we need feedback from you on the quality and types of benefits currently offered. Please answer as many questions as you can, basing your answers on actual experiences you have had. All of your responses are strictly confidential. Once you have completed the survey, place it in the box marked “SURVEY RESPONSES” located in the first floor lobby. Those of you who are not located at the (name location) office, please fax your completed survey to (XXX) XXX-XXXX. Please return the survey by (date). Thank you in advance for your cooperation.
I. Using a scale from 1 to 5 where “5” means very satisfied, “1” means very dissatisfied and “N/A” means you are not using the benefit, please circle the number that indicates your overall satisfaction with the individual benefits from our Plan.
Very Dissatisfied Very Satisfied Applicable
401(k) Retirement Plan 1 2 3 4 5 N/A
Health Insurance 1 2 3 4 5 N/A
Dental Insurance 1 2 3 4 5 N/A
Prescription Drug Card 1 2 3 4 5 N/A
Short Term Disability 1 2 3 4 5 N/A
Vision Plan 1 2 3 4 5 N/A
Holidays 1 2 3 4 5 N/A
Sick Leave 1 2 3 4 5 N/A
Vacation Leave 1 2 3 4 5 N/A
Floating Holiday 1 2 3 4 5 N/A
Flexible Spending Account 1 2 3 4 5 N/A
Jury Duty Leave (1 day) 1 2 3 4 5 N/A
Group Life Insurance 1 2 3 4 5 N/A
Dues for Professional Memberships/Subscriptions 1 2 3 4 5 N/A
Credit Union 1 2 3 4 5 N/A
Discount Movie Tickets 1 2 3 4 5 N/A
Discount Tickets for Sporting Events (via credit union) 1 2 3 4 5 N/A
II. What would you improve about the benefits offered by Company?
401(k) Retirement Plan:_________________________________________
Dental Insurance :_____________________________________________
Prescription Drug Card:_________________________________________
Short Term Disability:__________________________________________
Floating Holiday :___________________________________________
Flexible Spending Account:___________________________________
Jury Duty Leave (1 day) :_______________________________________
Group Life Insurance:_________________________________________
Dues for Professional Memberships/Subscriptions:__________________
Discount Movie Tickets:______________________________________
Discount Tickets for Sporting Events:____________________________
III. From the following list of new and improved benefits, pick the top 3 that you would like added to the Company Benefits Plan, where number “1” is your first choice and number 3 is your last.
___ 3 Weeks Vacation After 5 Years ___ 2 Personal Days
___ More Paid Holidays ___ 2 Floating Holidays
___ Educational/Tuition Reimbursement ___ Professional Development Opportunities
___ Vacation Time Accrues Upon Start Date ___Corporate Credit Card
___ Flex Time ___ Stock Options
___ Profit Sharing ___ Dependent/Elder Care Programs
___ 4.5-Day Work Week For Summer (4 9-hour work days) ___Increase Number of Sick Days
___ Compressed Work Week (4 10-hour work days) ___ Stress Reduction Program
___ 401(k) Vesting Period Reduced ___ Increase Employer Match on 401(k)
___ Company Newsletter ___ Travel Accident Insurance
___ Accidental Death & Dismemberment Insurance ___Mass Transit/Carpool Reimbursement
___ Wellness Program, Resources & Information ___ Health Club Membership Subsidiary
___ Employee “Computer” Purchase Assistance (Loans)
___ Formalized Orientation Program For New Employees
___ Other (please describe)_______________________________________
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