Q01
Message
All templatesEmployee & HR
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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
15 questions · ~8 min
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 TemplateThis 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 TemplateThis 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 TemplateA 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
Frequently asked questions
What questions are in the “Employee Health & Accommodation Needs Survey” template?
The template includes 15 ready-to-use questions, starting with: “Thanks for taking a few minutes for this check-in. This survey is completely voluntary and confidential — it's used only…” · “Before we start, please confirm you understand how this information will be used.” · “Do you currently have a health condition, injury, or disability that affects how you perform your job duties?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 15 questions in about 8 minutes.
Can I customize this template?
Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.
Is this template free to use?
Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.
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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