All templates
Industry-Specific

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 · ~12 min
Q01
Message

Welcome to the Mine Site Safety Culture Survey. This survey takes approximately 12 minutes. Your responses are confidential, anonymized, and reported only in aggregate to improve safety practices at this site. There are no right or wrong answers—we want your honest experience from the past 30 days. Participation is voluntary, and you may stop at any time. Please tap 'Next' to begin.

Q02
Multiple Choice

Are you currently working at or regularly visiting a mine site?

  • Yes
  • No
Q03
Opinion Scale

Over the past 30 days, safety was prioritized over production on my crew.

Scale: 17
Min:Strongly disagreeMax:Strongly agree
Q04
Multiple Choice

How do you usually report hazards, near misses, or incidents on this site? Select all that apply.

  • Tell supervisor in person
  • Paper or card
  • Radio/phone call
  • Mobile app
  • Computer kiosk/terminal
  • Safety hotline
  • Toolbox talk/team meeting
  • Other (please specify)
Q05
Multiple Choice

What, if anything, makes reporting harder on your site? Select all that apply.

  • Unclear what should be reported
  • Takes too much time to complete
  • Fear of blame or negative consequences
  • Little or no feedback after reporting
  • Reporting system is difficult to use
  • Belief that minor issues don't matter
  • Lack of supervisor support
  • Language or communication barriers
  • None—I don't experience barriers
  • Other (please specify)
Q06
Opinion Scale

In the past 30 days, I could report safety issues without fear of blame or punishment.

Scale: 17
Min:Strongly disagreeMax:Strongly agree
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
Dropdown

What is your primary job role on this site?

  • Operator/Production
  • Maintenance/Trades
  • Supervisor/Foreman
  • Safety/Health
  • Engineer/Planner
  • Other
Q09
Message

Thank you for completing this survey. Your input is valued and will be used to strengthen safety practices and reporting at this site.

Q10
Opinion Scale

Over the past 30 days, my supervisor consistently demonstrated a commitment to safety.

Scale: 17
Min:Strongly disagreeMax:Strongly agree
Q11
Dropdown

When a hazard or near miss occurs, how often do you personally report it? (past 30 days)

  • Every time
  • Most times
  • About half the time
  • Occasionally
  • Never
  • Not applicable (no issues observed)
Q12
Ranking

Please rank the following motivations for reporting from most to least important to you.

  1. Protect coworkers and myself
  2. Fix hazards quickly
  3. Company expects it
  4. Regulatory compliance
  5. Recognition for reporting
  6. Option to report anonymously
Drag to rank
Q13
Opinion Scale

In the past 30 days, I clearly understood what safety issues should be reported and how to report them.

Scale: 17
Min:Strongly disagreeMax:Strongly agree
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
Dropdown

What is your employment status?

  • Employee
  • Contractor
  • Visitor/Temporary
  • Other
Q16
Opinion Scale

Over the past 30 days, my coworkers looked out for each other's safety.

Scale: 17
Min:Strongly disagreeMax:Strongly agree
Q17
Dropdown

How many near-miss events did you personally observe in the past 30 days?

  • 0
  • 1–2
  • 3–5
  • 6–10
  • More than 10
Q18
Opinion Scale

In the past 30 days, I received meaningful feedback after submitting a safety report.

Scale: 17
Min:Strongly disagreeMax:Strongly agree
Q19
Dropdown

What shift do you typically work?

  • Day
  • Night
  • Rotating
  • Other
Q20
Opinion Scale

Over the past 30 days, safety information and updates were communicated clearly to my crew.

Scale: 17
Min:Strongly disagreeMax:Strongly agree
Q21
Multiple Choice

Which of the following have you reported in the past 30 days? Select all that apply.

  • Near miss
  • Minor injury (first aid)
  • Recordable injury
  • Unsafe condition/housekeeping
  • Equipment damage/failure
  • Environmental spill/release
  • Vehicle incident
  • None of the above
  • Other (please specify)
Q22
Dropdown

How long have you worked in mining?

  • Less than 1 year
  • 1–3 years
  • 4–9 years
  • 10–19 years
  • 20 or more years
Q23
Opinion Scale

Over the past 30 days, I received adequate training to perform my tasks safely.

Scale: 17
Min:Strongly disagreeMax:Strongly agree
Q24
Dropdown

On average, how many minutes does it take you to complete a typical safety report?

  • Less than 5 minutes
  • 5–10 minutes
  • 11–20 minutes
  • 21–30 minutes
  • More than 30 minutes
  • I have not filed a report
Q25
Dropdown

How long have you worked at this specific site?

  • Less than 1 month
  • 1–6 months
  • 7–12 months
  • 1–3 years
  • More than 3 years
Q26
Dropdown

What is your primary work environment?

  • Surface
  • Underground
  • Both
  • Other
Q27
Dropdown

Which region do you primarily work in?

  • North America
  • South America
  • Europe
  • Africa
  • Asia
  • Australia/New Zealand
  • Other

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.

Frequently asked questions

What questions are in the “Mine Site Safety Culture & Incident Reporting Assessment” template?

The template includes 27 ready-to-use questions, starting with: “Welcome to the Mine Site Safety Culture Survey. This survey takes approximately 12 minutes. Your responses are confident…” · “Are you currently working at or regularly visiting a mine site?” · “Over the past 30 days, safety was prioritized over production on my crew.”. The full set is previewed above, and every question is editable.

How long does this survey take to complete?

Respondents typically finish the 27 questions in about 12 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.

Related templates

More studies on similar topics.

See all
Industry-Specific

Marketplace Seller Trust & Transparency Assessment

Measures seller confidence in marketplace policies, dispute resolution, and earnings transparency to identify friction points and prioritize improvements that drive seller retention.

View template
Industry-Specific

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.

View template
Industry-Specific

Workplace Health & Safety Culture Survey

Measures how employees experience hazard awareness, incident reporting, and safety training in practice — not just policy on paper. An AI follow-up interview reconstructs what actually happened the last time someone saw or reported a safety issue, including any fear of retaliation, giving safety teams a real picture behind the scores.

View template
Industry-Specific

Medical Office Patient Safety Culture Survey (AHRQ-Aligned)

Benchmarks how staff in your medical office perceive teamwork, communication, error reporting, and leadership support for safety, modeled on AHRQ's patient safety culture domains. An AI follow-up interview digs into the most recent near-miss or error staff witnessed and what stopped or helped them report it.

View template
Industry-Specific

Nursing Home Patient Safety Culture Assessment

Surveys nursing home staff on teamwork, staffing adequacy, handoffs, communication openness, and overall resident safety, aligned with the AHRQ Nursing Home Survey on Patient Safety Culture framework. An AI follow-up interview reconstructs a recent safety event or near-miss to surface what actually happened versus what gets reported.

View template
Industry-Specific

Workplace Culture Health Assessment

Measures how employees actually experience company culture — psychological safety, values alignment, manager reinforcement, and day-to-day behavior — not just stated policy. An AI follow-up interview digs into the story behind the most telling rating, surfacing specific moments that a scale alone can't capture.

View template