Q01
Message
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Contactless Health Screening Experience Survey
Captures how people experience contactless health screening kiosks or apps—ease of use, trust in accuracy, and privacy comfort—for clinics, workplaces, and events. An AI follow-up interview digs into the specific moment trust broke down or friction occurred, beyond a simple satisfaction score.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
11 questions · ~6 min
Q02
Multiple ChoiceRequired
Where did you most recently go through a contactless health screening?
- Workplace or office building
- Clinic or hospital
- Airport or transit hub
- Event, venue, or gym
- School or campus
- Other (Replace with your own context if this list doesn't fit)
Q03
Opinion ScaleRequired
How easy was it to complete the screening (e.g., standing in front of a scanner, answering prompts on a kiosk)?
Scale: 1 – 7
Min:Very difficultMax:Very easy
Q04
Opinion ScaleRequired
How much do you trust that the screening result was accurate?
Scale: 1 – 7
Min:Don't trust it at allMax:Trust it completely
Q05
MatrixRequired
Thinking about that same screening, how much do you agree with each statement?
5 rows × 5 columns
- It was faster than a manual check-in
- I understood what was being measured or asked
- I felt my personal health data was handled respectfully
- Staff or signage made the process clear
- I would be comfortable going through it again
Columns: Strongly disagree · Disagree · Neutral · Agree · Strongly agree
Q06
Multiple Choice
In the last time you used it, did you run into any of these issues?
- Long wait or queue
- Device didn't read correctly on the first try
- Confusing instructions
- Concerned about who sees my data
- Felt rushed or watched by staff
- Screening flagged me incorrectly
Q07
Rating ScaleRequired
Overall, how satisfied were you with the contactless screening experience?
Range: 1 – 5
Min:Very dissatisfiedMax:Very satisfied
Q08
AI Interview
Reconstruct the respondent's most recent contactless screening moment in concrete detail: what device or app was used, what happened step by step, and whether the result felt accurate. If they reported low trust or an issue (long wait, misread, data concerns, incorrect flag), probe exactly what happened, how staff responded, and what would have restored their confidence. If everything went smoothly, ask what specifically made it feel trustworthy and fast.
Q09
Multiple Choice
What is your age range?
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65 or older
- Prefer not to say
Q10
Multiple Choice
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q11
Message
That's everything — thank you for sharing your experience! Your answers, along with the follow-up conversation, will help the teams running these screenings make the process faster, clearer, and more trustworthy.
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 reconstructs the respondent's actual screening moment to find where trust broke down or friction occurred, not just a satisfaction number
- Combines an opinion-scale trust/ease pair with a matrix of agreement statements and a specific issues checklist, giving both breadth and depth on the same recent experience
- Uses transparent, auto-generated reporting so clinics, workplaces, and event organizers can see exactly what was asked and why
- Structured to work across contexts (clinics, workplaces, events) rather than locking into one vertical like airlines or a single symptom-check use case
QuestionPro
Contactless Health-Screening Survey Template for AirlinesThis is a fielding-ready static template but scoped specifically to airline travelers rather than clinics, workplaces, or events. It covers standard satisfaction and trust questions but has no mechanism to probe deeper on individual answers. Useful as a narrow vertical starting point, less useful for broader contactless screening research.
What it does well
- Purpose-built for the airline travel context
- Likely quick to deploy as-is for that niche
- Comes from an established survey platform with broad template library
Where it falls short
- Static question set with no adaptive follow-up when a respondent flags low trust or friction
- No voice interview or guided screen-share option to observe the actual screening moment
- No transparent, publishable prompt methodology since there are no AI-driven questions at all
Jotform
COVID-19 Daily Health Screening Form TemplateThis is a daily symptom-check intake form rather than an experience/satisfaction survey about contactless kiosks or apps — it's built for operational screening logs, not for understanding trust or friction in the screening experience itself. It's fielding-ready but serves a different purpose than an experience research template.
What it does well
- Simple, fast form intended for daily operational use
- Familiar Jotform builder for easy customization of fields
- Free-tier accessible template
Where it falls short
- Designed for symptom logging, not for capturing trust, ease-of-use, or privacy comfort with the screening technology itself
- No adaptive follow-up interview to dig into a specific bad experience
- No automated quality scoring or auto-generated experience report
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.