Q01
Message
All templates
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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
13 questions · ~7 min
Q02
Multiple ChoiceRequired
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
MatrixRequired
Thinking about a typical work day, how much difficulty do you currently experience with each of the following?
7 rows × 4 columns
- 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
- +2 more
Columns: No difficulty · Mild difficulty · Significant difficulty · Unable without assistance
Q04
Opinion ScaleRequired
In the last 30 days, how much has your condition limited your ability to complete your primary work or daily tasks?
Scale: 1 – 10
Min:Not at allMax:Completely prevents me
Q05
Multiple ChoiceRequired
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
RankingRequired
Of the following potential accommodations, rank them from most to least helpful for improving your ability to do your job.
- Flexible or modified schedule
- Ergonomic or assistive equipment
- Additional rest breaks
- Remote or hybrid work option
- Modified job duties
- Additional support staff or job coaching
Drag to rank
Q07
Rating ScaleRequired
How confident are you that your current accommodations meet your day-to-day needs?
Range: 1 – 5
Min:Not confidentMax:Very confident
Q08
AI Interview
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
Long Text
Is there anything about your functional limitations or accommodation needs that this assessment hasn't captured?
Q10
Multiple Choice
Which age range do you fall into?
- Under 25
- 25–34
- 35–44
- 45–54
- 55–64
- 65 or older
Q11
Multiple Choice
What is your current employment status?
- Full-time employee
- Part-time employee
- On leave
- Not currently employed
Q12
Multiple Choice
What is your gender identity?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q13
Message
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.
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 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 TemplateA 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.
What it does well
- Quick to deploy using Jotform's widely-used drag-and-drop builder
- Easily customizable fields and layout
- Familiar form format for HR intake workflows
Where it falls short
- 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 formA 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.
What it does well
- Clean, conversational one-question-at-a-time interface
- Strong visual design and mobile-friendly presentation
- Simple to set up for basic screening use cases
Where it falls short
- 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
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.