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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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샘플 질문

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질문 13개 · 약 7분
Q01
메시지

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
객관식필수

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
매트릭스필수

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

7개 행 × 4개 열
  • 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
  • 외 2개
열: No difficulty · Mild difficulty · Significant difficulty · Unable without assistance
Q04
의견 척도필수

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

척도: 1 – 10
최소:Not at all최대:Completely prevents me
Q05
객관식필수

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
순위 매기기필수

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
드래그하여 순위 지정
Q07
평점 척도필수

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

범위: 1 – 5
최소:Not confident최대:Very confident
Q08
AI 인터뷰

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
장문형

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

Q10
객관식

Which age range do you fall into?

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

What is your current employment status?

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

What is your gender identity?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q13
메시지

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.

포함된 기능

  • AI 후속 질문

    정형화된 설문이 놓치는 세부 내용을, 주관식 답변에 맞춰 AI가 심층 질문으로 끌어냅니다.

  • 주의력 확인 장치

    성의 없는 답변과 저품질 응답자를 걸러내는 내장 안전장치입니다.

  • AI가 작성한 문안

    문구, 질문 순서, 분기 로직까지 AI가 연구 목표에 맞춰 작성합니다.

  • 자동 리포트

    응답이 모이면 주요 주제, 인용문, 이해하기 쉬운 요약이 자동으로 작성됩니다.

다른 서비스와 비교

다른 설문 도구의 가장 유사한 템플릿을 검토했습니다. 그 도구들이 잘하는 점과, 이 템플릿이 한발 더 나아가는 지점을 정리했습니다.

이 템플릿을 선택하는 이유

  • 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.

잘하는 점

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

아쉬운 점

  • 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.

잘하는 점

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

아쉬운 점

  • 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

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