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Workplace Health & Safety Culture Survey

Measures how employees experience hazard awareness, incident reporting, and safety training in practice — not just policy on paper. An AI follow-up interview reconstructs what actually happened the last time someone saw or reported a safety issue, including any fear of retaliation, giving safety teams a real picture behind the scores.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

14 questions · ~7 min
Q01
Message

Thanks for taking a few minutes on this one — it's about your day-to-day experience with safety at work, not a compliance quiz. Honest answers help us fix real gaps. About 8 minutes.

Q02
Multiple ChoiceRequired

In the last 30 days, how often have you noticed a safety hazard (spill, blocked exit, damaged equipment, exposed wiring, etc.) at your workplace?

  • Never
  • Once
  • A few times
  • Weekly or more
  • I'm not sure
Q03
Opinion ScaleRequired

How comfortable do you feel reporting a safety concern without worrying about negative consequences for yourself?

Scale: 1 – 5
Min:Not comfortable at allMax:Extremely comfortable
Q04
MatrixRequired

How much do you agree with each statement about safety at your workplace?

4 rows × 5 columns
  • My manager treats safety as a top priority
  • I know how to report a hazard or unsafe condition
  • The safety training I've received prepares me for my actual job tasks
  • I feel free to stop work if something seems unsafe, without pushback
Columns: Strongly disagree · Disagree · Neutral · Agree · Strongly agree
Q05
Multiple ChoiceRequired

In the last 6 months, have you witnessed or personally experienced a safety incident or near-miss at work?

  • Yes
  • No
  • Not sure
Q06
Multiple Choice

If you witnessed or experienced that incident, did you report it?

  • Yes, I reported it
  • No, I did not report it
  • I wasn't sure how or who to report it to
  • Not applicable — I haven't witnessed one
Q07
Best–Worst Trade-off (MaxDiff)Required

Which of these safety improvements matter most to you?

  • Additional or better-fitting personal protective equipment
  • More frequent hands-on safety training
  • Clearer hazard signage and labeling
  • Faster follow-up after incidents are reported
  • Regular equipment and machinery maintenance checks
  • Ergonomic workstation improvements
  • Mental health and stress-related safety support
  • More frequent emergency evacuation drills
Pick best & worst per setBest:Matters most to meWorst:Matters least to me
Q08
Rating ScaleRequired

How satisfied are you with the safety training you've received?

Range: 1 – 5
Min:Not satisfied at allMax:Extremely satisfied
Q09
AI Interview

Explore what actually happened the last time this person witnessed or experienced a safety incident or near-miss: what it was, who they told (or didn't), how it was handled, and whether fear of retaliation played any role. If they said they'd feel uncomfortable reporting a concern, probe exactly what would need to change for that to feel safe. If they haven't witnessed an incident, ask what would make them confident enough to speak up if they did.

Q10
Long Text

Is there anything specific about safety at your workplace you'd like leadership to know that these questions didn't cover?

Q11
Multiple Choice

Which best describes your role type?

  • Frontline/production
  • Office/administrative
  • Field or mobile work site
  • Supervisory/management
  • Other
  • Prefer not to say
Q12
Multiple Choice

How long have you worked at this organization?

  • Less than 6 months
  • 6 months to 2 years
  • 2 to 5 years
  • More than 5 years
  • Prefer not to say
Q13
Multiple Choice

What is your primary work setting?

  • On-site/in-person
  • Remote
  • Hybrid
  • Field/mobile
  • Prefer not to say
Q14
Message

Thank you for being honest with us. Your responses will be reviewed by the safety and HR team (anonymously, in aggregate) to prioritize real fixes — not just paperwork.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • Goes beyond static agree/disagree questions with an AI follow-up interview that reconstructs what actually happened the last time someone witnessed or reported a hazard, including any fear of retaliation.
  • Pairs quantitative measures (hazard-noticing frequency, training satisfaction rating, agreement matrix, max-diff on improvement priorities) with open-ended and conversational follow-up to surface the story behind the scores.
  • Directly asks whether an incident was reported and, if not, lets the AI interview probe why — giving safety teams visibility into underreporting instead of just top-line satisfaction numbers.
  • Closes with a transparent chat message telling respondents their answers will be reviewed by the safety team, supporting honest reporting on a sensitive topic.

Jotform

Workplace Health Safety Survey Form Template

A fielding-ready static form covering standard workplace safety topics, built on Jotform's drag-and-drop form builder. It's designed for quick deployment and easy customization rather than deep qualitative exploration. No mechanism to follow up on individual incidents or probe the context behind a low score.

What it does well

  • Fast to deploy and customize using a familiar drag-and-drop form builder
  • Broad template library ecosystem for related HR/compliance forms
  • Likely supports standard question types and basic conditional logic

Where it falls short

  • Static question set with no adaptive follow-up to reconstruct what happened during a specific incident
  • No AI-driven or voice interview option to explore retaliation fears or reporting hesitancy
  • No published methodology on how questions were validated or scored

QuestionPro

Workplace Health and Safety Questionnaire

A structured questionnaire template covering hazard awareness, training, and incident-related topics, offered within QuestionPro's broader survey platform. It's a conventional fielding-ready template with standard analytics rather than conversational follow-up. Useful for benchmarking scores but not for surfacing the narrative behind a reported (or unreported) incident.

What it does well

  • Established survey platform with standard reporting and dashboard analytics
  • Template covers core H&S themes like hazard awareness and training
  • Supports typical question branching and segmentation by role or tenure

Where it falls short

  • No adaptive AI interview to dig into the specifics of a witnessed or reported incident
  • No voice-based interview option for respondents who prefer speaking over typing
  • Automated per-response quality scoring and transparent AI prompts are not part of the offering

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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