Q01
Long Text
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Mine Site Safety Culture & Incident Reporting Assessment
Measures safety climate perceptions, incident/near-miss reporting behaviors, and barriers to reporting among mine-site personnel. Designed to identify risk gaps and prioritize safety-culture interventions across shifts, roles, and work environments.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
27 questions · ~4 min
Q02
Multiple Choice
Are you currently working at or regularly visiting a mine site?
Q03
Long Text
Over the past 30 days, safety was prioritized over production on my crew.
Q04
Multiple Choice
How do you usually report hazards, near misses, or incidents on this site? Select all that apply.
Q05
Multiple Choice
What, if anything, makes reporting harder on your site? Select all that apply.
Q06
Long Text
In the past 30 days, I could report safety issues without fear of blame or punishment.
Q07
AI Interview
We'd like to learn a bit more about your safety reporting experience. An AI moderator will ask you 1–2 brief follow-up questions based on your responses.
Q08
Long Text
What is your primary job role on this site?
Q09
Long Text
Thank you for completing this survey. Your input is valued and will be used to strengthen safety practices and reporting at this site.
Q10
Long Text
Over the past 30 days, my supervisor consistently demonstrated a commitment to safety.
Q11
Long Text
When a hazard or near miss occurs, how often do you personally report it? (past 30 days)
Q12
Long Text
Please rank the following motivations for reporting from most to least important to you.
Q13
Long Text
In the past 30 days, I clearly understood what safety issues should be reported and how to report them.
Q14
Long Text
Based on your responses in this survey, what would make safety reporting easier or more effective at this site? Please share any additional thoughts.
Q15
Long Text
What is your employment status?
Q16
Long Text
Over the past 30 days, my coworkers looked out for each other's safety.
Q17
Long Text
How many near-miss events did you personally observe in the past 30 days?
Q18
Long Text
In the past 30 days, I received meaningful feedback after submitting a safety report.
Q19
Long Text
What shift do you typically work?
Q20
Long Text
Over the past 30 days, safety information and updates were communicated clearly to my crew.
Q21
Multiple Choice
Which of the following have you reported in the past 30 days? Select all that apply.
Q22
Long Text
How long have you worked in mining?
Q23
Long Text
Over the past 30 days, I received adequate training to perform my tasks safely.
Q24
Long Text
On average, how many minutes does it take you to complete a typical safety report?
Q25
Long Text
How long have you worked at this specific site?
Q26
Long Text
What is your primary work environment?
Q27
Long Text
Which region do you primarily work in?
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.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.