QuestionPunkQuestionPunk
Start free
All templates

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.

Use this templateBrowse more templates

Sample questions

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

15 questions · ~8 min
Q01
Message

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
ConsentRequired

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

Q03
Multiple Choice

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
Multiple Choice

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
Opinion Scale

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

Scale: 1 – 5
Min:Not meeting my needs at allMax:Fully meeting my needs
Q06
Multiple Choice

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
Long Text

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
Multiple Choice

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
Matrix

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

5 rows × 3 columns
  • Mental health support
  • Ergonomic assessments
  • Chronic condition management resources
  • Flexible scheduling for medical appointments
  • On-site or virtual health screenings
Columns: Not interested · Somewhat interested · Very interested
Q10
AI Interview

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
Message

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

Q12
Multiple Choice

Which age range do you fall into?

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

How do you describe your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q14
Multiple Choice

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
Message

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.

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

  • 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.

What it does well

  • 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

Where it falls short

  • 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.

What it does well

  • 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

Where it falls short

  • 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.

What it does well

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

Where it falls short

  • 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

Ready to launch?

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

Use this templateStart free