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Safety · Form

Sample Form: گزارش شبه‌حادثه

اتفاقی که نزدیک بود حادثه شود: محل، شرح، علت احتمالی و پیشنهاد — ناشناس اختیاری.

9 questions · Free up to 50 responses a month

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About this template

“گزارش شبه‌حادثه” has 9 questions; 4 are required and 5 optional. Question types: Long text (3), Short text (2), Department (1), Date and time (1), Dropdown (1), File upload (1). 15 ready-made options across 2 choice questions, all editable in the online version.

In the online version of this template

  • Dates are picked and stored on the Jalali (Persian) calendar.
  • Attached files are stored with the response.
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Questions in this template

  1. 1.

    نام (اختیاری)

    (Short text)
  2. 2.

    واحد

    (Department)
    • مدیریت
    • مالی
    • فروش
    • بازاریابی
    • فناوری اطلاعات
    • منابع انسانی
    • عملیات
    • پشتیبانی
  3. 3.

    زمان *

    (Date and time)
  4. 4.

    محل *

    (Short text)
  5. 5.

    نوع *

    (Dropdown)
    • سقوط از ارتفاع
    • برق
    • مواد شیمیایی
    • ماشین‌آلات
    • لغزش
    • آتش
    • سایر
  6. 6.

    چه اتفاقی افتاد؟ *

    (Long text)
  7. 7.

    علت احتمالی

    (Long text)
  8. 8.

    پیشنهاد پیشگیری

    (Long text)
  9. 9.

    عکس

    (File upload)

Printable or online?

Printable version (Word & PDF)

  • For filling in on paper, signing and filing by hand
  • Edit the Word file any way you like
  • Collecting and typing up the answers is up to you
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Online version on Porsino

  • Answers are collected and organised automatically — no retyping
  • National ID, mobile number and dates are validated instantly
  • Ready-made reports and charts, plus Excel export in one click
  • Share a link or QR code — it works on mobile too
Build the online version for free

How do I use this template?

  1. Sign up for Porsino for free; no bank card needed.
  2. In the panel, open “Templates” and choose “گزارش شبه‌حادثه”.
  3. Change the questions as you like, publish the form and send the link.

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