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Employee & HR

Employee Health & Accommodation Needs Survey

A voluntary, confidential survey for HR and benefits teams to understand employees' current health-related work accommodation needs and wellness-benefit priorities — not a diagnostic or pre-employment screening tool. The AI follow-up interview explores accommodation gaps and barriers respondents might not fully describe in a closed-ended answer, so support can be tailored rather than generic.

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設問の例

テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。

全15問・約8分
Q01
メッセージ

Thanks for taking a few minutes for this check-in. This survey is completely voluntary and confidential — it's used only to help HR and benefits plan accommodations and wellness support, never for hiring, performance, or discipline decisions. You can skip any question. About 8 minutes.

Q02
同意必須

Before we start, please confirm you understand how this information will be used.

Q03
選択式

Do you currently have a health condition, injury, or disability that affects how you perform your job duties?

  • Yes
  • No
  • Prefer not to say
Q04
選択式

Which of the following workplace accommodations are you currently using or think you might need? (Select all that apply)

  • Flexible or adjusted schedule
  • Ergonomic equipment or workstation changes
  • Remote or hybrid work arrangement
  • Modified duties or workload
  • Assistive technology
  • Additional breaks
  • None currently needed
Q05
オピニオンスケール

If you're using any accommodation today, how well is it meeting your needs?

スケール: 1 – 5
最小:Not meeting my needs at all最大:Fully meeting my needs
Q06
選択式

Is there a medical condition emergency responders or your manager should know about in case of a workplace emergency (e.g., severe allergy, seizure disorder)?

  • Yes
  • No
  • Prefer not to say
Q07
自由回答（長文）

If you'd like, describe any accommodation or support that would help you do your job more effectively. Share only what you're comfortable sharing.

Q08
選択式

In the last 90 days, which of these workplace wellness resources have you actually used?

  • Employee assistance / counseling program
  • Gym or fitness benefit
  • Mental health app or service
  • On-site or telehealth medical visit
  • None of these
Q09
マトリクス

How interested would you be in each of the following if your employer expanded it?

5行 × 3列
  • Mental health support
  • Ergonomic assessments
  • Chronic condition management resources
  • Flexible scheduling for medical appointments
  • On-site or virtual health screenings
列: Not interested · Somewhat interested · Very interested
Q10
AIインタビュー

Anchor on the respondent's accommodation and emergency-info answers. If they indicated a need or gap, explore specifically what is and isn't working today, what has changed recently, and what a fully supportive setup would look like for their role. If they said 'none needed', gently confirm whether that's because needs are already met or because they're hesitant to disclose, and note any barriers to speaking up without pressing for a diagnosis.

Q11
メッセージ

Just a couple of optional background questions, then we're done.

Q12
選択式

Which age range do you fall into?

  • Under 25
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65+
  • Prefer not to say
Q13
選択式

How do you describe your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q14
選択式

How long have you worked at the company?

  • Less than 1 year
  • 1-3 years
  • 4-7 years
  • 8+ years
  • Prefer not to say
Q15
メッセージ

Thank you for sharing this with us. Your responses go directly to HR/benefits staff to improve accommodations and wellness support — they are kept confidential and are never used in hiring or performance decisions.

含まれる機能

  • AIによる深掘り

    自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。

  • 注意確認設問

    急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。

  • AIが作成する設問文

    文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。

  • 自動レポート

    回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。

他ツールとの比較

ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。

このテンプレートを選ぶ理由

  • Includes an AI follow-up interview that's anchored specifically on accommodation and emergency-info answers, so it can probe gaps a static form would miss
  • Combines closed-ended intake (condition/accommodation status, emergency-info flag, 90-day wellness usage) with a long-text open response and a matrix of interest in expanded benefits, giving both quantifiable and narrative data
  • Opens with an explicit consent step and voluntary/confidential framing, positioning it as a benefits-planning tool rather than a diagnostic or pre-employment screen
  • Closes with optional demographic questions and a clear statement that responses route to HR/benefits staff, supporting transparent, consent-based reporting

SurveySparrow

Employee Medical History Form Template

This is a static medical-history intake form focused on capturing conditions and history fields rather than accommodation needs or wellness priorities. It's fielding-ready as a form but doesn't appear designed to explore workplace barriers or benefit preferences in depth.

優れている点

  • Ready-to-use form format for basic medical history capture
  • Likely supports SurveySparrow's standard branching/logic for conditional fields
  • Familiar form UI that's quick for respondents to complete

物足りない点

  • No adaptive follow-up to probe unclear or incomplete answers
  • Framed around medical history capture, not ongoing accommodation/benefit needs
  • No published methodology for how responses are scored or interpreted

Jotform

Employee Accommodation Form Template

This is the closest topical match, a static form for requesting or documenting workplace accommodations. It's fielding-ready and likely customizable via Jotform's builder, but it functions as a one-way request form rather than a two-way exploratory survey.

優れている点

  • Directly targets accommodation requests, aligning well with the topic
  • Jotform's drag-and-drop builder allows easy customization of fields
  • Supports file uploads/e-signatures common to HR documentation workflows

物足りない点

  • No adaptive AI interview to surface accommodation gaps respondents don't fully articulate in closed fields
  • No built-in quality scoring of open-text responses
  • No voice-based interview option for respondents who prefer speaking over typing

Typeform

Employee Medical Form Template

A conversational-style static form for collecting employee medical information, benefiting from Typeform's polished one-question-at-a-time UX. It covers intake fields but doesn't appear to include adaptive questioning or wellness-benefit prioritization content.

優れている点

  • Clean, conversational UI that can improve completion rates
  • Simple to adapt question wording within Typeform's editor
  • Good for straightforward medical-info intake

物足りない点

  • No adaptive AI follow-up to explore accommodation barriers beyond scripted questions
  • No automated quality scoring of responses
  • No transparent, publishable prompt methodology behind question flow

よくあるご質問

「Employee Health & Accommodation Needs Survey」テンプレートにはどのような設問が含まれていますか？

すぐに使える設問が15問含まれており、最初の設問は次のとおりです：「Thanks for taking a few minutes for this check-in. This survey is completely voluntary and confidential — it's used only…」・「Before we start, please confirm you understand how this information will be used.」・「Do you currently have a health condition, injury, or disability that affects how you perform your job duties?」。すべての設問は上でプレビューでき、自由に編集できます。

このアンケートの回答にはどのくらい時間がかかりますか？

回答者は通常、15問を約8分で回答し終えます。

テンプレートは編集できますか？

はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。

このテンプレートは無料で使えますか？

はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。

公開の準備はできましたか？

このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。

このテンプレートを使う無料で始める

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