Q01
Message
All templates
Workplace Safety Climate and Incident Reporting Survey
Measures how safe employees feel day-to-day, how strong your safety culture and reporting habits actually are, and what stops people from speaking up — with an AI follow-up that reconstructs a real near-miss or incident and what would change how it's handled next time.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
14 questions · ~7 min
Q02
Multiple ChoiceRequired
In the last 12 months, how many workplace safety trainings have you completed?
- None
- One
- Two to three
- Four or more
Q03
Opinion ScaleRequired
Overall, how safe do you feel doing your day-to-day tasks at work?
Scale: 1 – 10
Min:Not safe at allMax:Extremely safe
Q04
MatrixRequired
How much do you agree with each statement about safety where you work?
5 rows × 5 columns
- Safety equipment and PPE are well-maintained and available when I need them.
- Safety procedures for my role are clear and easy to follow.
- I feel comfortable raising a safety concern without fear of blame.
- My supervisor treats safety as a genuine priority, not just a checkbox.
- I know exactly how to report a safety incident or near-miss.
Columns: Strongly disagree · Disagree · Neutral · Agree · Strongly agree
Q05
Multiple ChoiceRequired
In the last 6 months, have you personally experienced or witnessed a workplace safety incident or near-miss?
- Yes, and I reported it
- Yes, but I did not report it
- No, not that I'm aware of
Q06
Multiple Choice
What, if anything, has stopped you from reporting a safety concern in the past?
- Didn't think it was serious enough
- Wasn't sure who to tell or how
- Worried about blame or repercussions
- Didn't think anything would change as a result
- Too busy or forgot
Q07
Best–Worst Trade-off (MaxDiff)Required
Which of these would do the most, and the least, to improve safety in your day-to-day work?
- Better personal protective equipment (PPE)
- More frequent safety training
- Clearer safety signage and labeling
- Faster response when incidents are reported
- Additional staffing during high-risk tasks
- Better lighting and facility maintenance
- More open communication about past incidents
Pick best & worst per setBest:Would improve safety the mostWorst:Would improve safety the least
Q08
AI Interview
Reconstruct one specific near-miss or safety incident the respondent experienced or witnessed in the last 6 months: what happened, what they did in the moment, and whether they reported it. If they reported it, ask what happened after — did anything change? If they didn't report it, dig into the real reason (not just the checkbox reason) and ask what would have made them report it. Keep it concrete and behavioral, not hypothetical.
Q09
Rating ScaleRequired
How confident are you that management actually acts on safety concerns once they're reported?
Range: 1 – 5
Min:Not at all confidentMax:Extremely confident
Q10
Long Text
What's one change that would make you feel safer at work? Be as specific as you'd like.
Q11
Multiple Choice
Which area of the business do you work in? (Template note: replace these with your own department list before launching.)
- Operations
- Warehouse/Production
- Office/Administrative
- Field/Delivery
- Other
- Prefer not to say
Q12
Multiple Choice
How long have you worked here?
- 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 shift do you typically work?
- Day shift
- Evening shift
- Night shift
- Rotating/variable shift
- Prefer not to say
Q14
Message
Thanks for your honesty — this really helps. Responses are combined into a safety report for leadership, and specifics from the follow-up conversation help us fix real gaps in how incidents get reported and handled.
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 scaled ratings with an AI follow-up interview that reconstructs one specific near-miss or incident and probes what would change how it's handled next time — something static forms can't do
- Combines quantitative signals (opinion scale on daily safety, a matrix of safety-culture agreement statements, and a MaxDiff to rank what would most improve day-to-day safety) with open-ended long-text on what change would make people feel safer
- Directly measures reporting barriers with a dedicated question on what's stopped people from reporting, plus a rating on whether management actually acts on concerns — closing the loop from perception to action
- Segments results by department, tenure, and shift so safety leaders can see where risk and silence are concentrated, then auto-generates a summary report from combined responses
SurveySparrow
Free Workplace Safety Templates That Actually WorkThis reads as a roundup/landing page of multiple free workplace safety templates rather than a single fielding-ready survey. SurveySparrow's conversational chat-style UI is a reasonable fit for this topic, but the page is oriented toward browsing templates rather than one deep, ready-to-send instrument.
What it does well
- Chat-style conversational format that can feel more human than a plain form
- Multiple free template variants to choose from
- Likely easy to customize and brand within their builder
Where it falls short
- No adaptive AI follow-up — questions are fixed regardless of what a respondent says
- No mention of voice AI interviews or automated per-response quality scoring
- Positioned as a template gallery/guide rather than a single deployable safety-climate instrument
Jotform
Workplace Safety and Concerns Form TemplateA straightforward form-builder template for logging safety concerns, which is useful for intake but is structurally a form rather than a survey designed to measure safety climate. It benefits from Jotform's drag-and-drop customization and widget ecosystem, but has no research-style question logic built in.
What it does well
- Highly customizable fields via drag-and-drop form builder
- Easy to embed or share for quick concern intake
- Free tier available for basic use
Where it falls short
- No adaptive AI interviewing or incident reconstruction — just static form fields
- No automated quality scoring of open-text responses
- Framed as a concerns/incident form, not a full safety-climate and reporting-culture survey
QuestionPro
Employee Safety Survey Questions + Sample Questionnaire TemplateThis is primarily a guide-style page with sample survey questions and explanations rather than a one-click deployable template. QuestionPro brings established survey-research credibility and analytics, but the page itself reads as educational content plus a downloadable question set.
What it does well
- Sample questionnaire draws on established survey-research question types
- Backed by QuestionPro's broader analytics and dashboard tooling
- Useful as a reference for building question logic manually
Where it falls short
- No adaptive AI follow-up or incident reconstruction — questions are pre-written and static
- Page functions as a guide/article with sample questions, not a ready-to-field instrument
- No mention of voice AI or automated quality scoring of responses
Typeform
Employee Safety Survey TemplateA polished one-question-at-a-time conversational survey template, which is the closest product analog to QuestionPunk's interface style. It likely supports branching logic for a smoother respondent experience, but has no AI-driven follow-up or incident reconstruction built in.
What it does well
- Clean one-question-at-a-time conversational UX
- Conditional/branching logic to route respondents
- Easy to theme and share, good completion rates typical of Typeform
Where it falls short
- No adaptive AI interviewer — follow-up questions are pre-set, not generated from the respondent's actual answer
- No voice AI interview option or automated per-response quality scoring
- No built-in mechanism to reconstruct a specific near-miss/incident in the respondent's own words
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.