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Industry-Specific

Workplace Disability Accommodation Needs Assessment

Assesses how a disability or health condition affects someone's ability to perform daily work tasks and which accommodations are working or missing. Built for HR, disability management, and occupational health teams, with an AI follow-up that turns the single biggest functional barrier into a concrete, real-world example instead of a checkbox.

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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13問・約7分
Q01
メッセージ

Thanks for taking a few minutes for this accommodation needs assessment. Your answers help us understand what's working and what support might help you do your job well. This is confidential and takes about 5 minutes.

Q02
選択式必須

What is the primary purpose of this assessment today?

  • New accommodation request
  • Periodic review of existing accommodations
  • Return-to-work planning
  • Benefits or eligibility determination
Q03
マトリクス必須

Thinking about a typical work day, how much difficulty do you currently experience with each of the following?

7行 × 4列
  • Walking or standing for extended periods
  • Fine motor tasks (typing, writing, handling objects)
  • Reading small print or screens
  • Hearing conversations in noisy settings
  • Concentrating on a task for 30+ minutes
  • ほか2件
列: No difficulty · Mild difficulty · Significant difficulty · Unable without assistance
Q04
オピニオンスケール必須

In the last 30 days, how much has your condition limited your ability to complete your primary work or daily tasks?

スケール: 1 – 10
最小:Not at all最大:Completely prevents me
Q05
選択式必須

Which accommodations, if any, are you currently using?

  • Modified or flexible schedule
  • Assistive technology or software
  • Physical workspace modifications
  • Reduced or modified duties
  • Remote or hybrid work arrangement
  • Additional rest breaks
Q06
ランク付け必須

Of the following potential accommodations, rank them from most to least helpful for improving your ability to do your job.

  1. Flexible or modified schedule
  2. Ergonomic or assistive equipment
  3. Additional rest breaks
  4. Remote or hybrid work option
  5. Modified job duties
  6. Additional support staff or job coaching
ドラッグして順位を付ける
Q07
評価スケール必須

How confident are you that your current accommodations meet your day-to-day needs?

範囲: 1 – 5
最小:Not confident最大:Very confident
Q08
AIインタビュー

Identify the activity the respondent rated as most difficult and ask them to walk through a specific, recent day it got in the way of work — what happened, what workaround (if any) they used, and what would have made it easier. If they reported no significant difficulty anywhere, ask whether they anticipate needs changing soon (e.g., progressive condition, upcoming treatment) and what would prompt them to request support. Probe gently for any accommodation they've wanted to ask for but haven't, and why.

Q09
自由回答（長文）

Is there anything about your functional limitations or accommodation needs that this assessment hasn't captured?

Q10
選択式

Which age range do you fall into?

  • Under 25
  • 25–34
  • 35–44
  • 45–54
  • 55–64
  • 65 or older
Q11
選択式

What is your current employment status?

  • Full-time employee
  • Part-time employee
  • On leave
  • Not currently employed
Q12
選択式

What is your gender identity?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q13
メッセージ

Thank you for sharing this. Your responses go directly to your accommodation review team to help identify and adjust the support that works best for you.

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 a matrix and opinion-scale question that quantify difficulty and functional limitation across daily work tasks, not just a single generic checkbox
  • Uses an AI follow-up interview that identifies the single activity rated as most difficult and asks the respondent to walk through a real-world example of it, turning a rating into concrete detail
  • Separately captures accommodations currently in use, a ranked preference of potential accommodations, and confidence that current accommodations meet daily needs, giving HR/occupational health a fuller picture than a static checklist
  • Closes with an open-ended long-text question for anything not otherwise captured, plus demographic questions for equity/compliance reporting, before routing responses to the accommodation review team

Jotform

Disability Assessment Form Template

A static, drag-and-drop form template for capturing disability-related information, built on Jotform's general form builder. It's ready to field quickly and is easy to customize with their editor, but it functions as a fixed questionnaire rather than an adaptive interview. No mention of follow-up probing or automated scoring of individual responses.

優れている点

  • Quick to deploy using Jotform's widely-used drag-and-drop builder
  • Easily customizable fields and layout
  • Familiar form format for HR intake workflows

物足りない点

  • No adaptive AI follow-up questions — every respondent sees the same static fields regardless of their answers
  • No automated per-response quality scoring
  • No voice-based interview option or guided task/screen-share capability

Typeform

Disability assessment form

A conversational, one-question-at-a-time form template built on Typeform's polished UI. It offers a nicer respondent experience than a plain form but the question flow and branching logic are still author-defined in advance, not generated dynamically from a respondent's specific answer. No published methodology for how any branching is scored or applied.

優れている点

  • Clean, conversational one-question-at-a-time interface
  • Strong visual design and mobile-friendly presentation
  • Simple to set up for basic screening use cases

物足りない点

  • Logic branches are pre-set, not an AI follow-up that dynamically probes the respondent's specific stated barrier
  • No automated scoring of response quality or completeness
  • No voice AI interview mode or guided screen-share task functionality

よくあるご質問

「Workplace Disability Accommodation Needs Assessment」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13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 accommodation needs assessment. Your answers help us understand what's working…」・「What is the primary purpose of this assessment today?」・「Thinking about a typical work day, how much difficulty do you currently experience with each of the following?」。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、13問を約7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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