Start for free
Safety · Form

Sample Form: گزارش ناشناس شبه‌حادثه

اتفاقی که می‌توانست حادثه شود ولی نشد — بی‌نام هم می‌شود فرستاد.

10 questions · Free up to 50 responses a month

Build a form from this templateDownload WordDownload PDFAll templates

Print-ready Word and PDF files — free, no sign-up.

About this template

“گزارش ناشناس شبه‌حادثه” has 10 questions; 5 are required and 5 optional. Question types: Long text (3), Short text (1), Department (1), Date and time (1), Dropdown (1), Single choice (1), File upload (1), Map location (1). 19 ready-made options across 3 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.
Related:Online form builder

Questions in this template

  1. 1.

    نام (اختیاری)

    (Short text)
  2. 2.

    واحد/محل *

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

    زمان *

    (Date and time)
  4. 4.

    نوع *

    (Dropdown)
    • سقوط از ارتفاع
    • لغزش
    • برخورد با تجهیزات
    • مواد شیمیایی
    • برق
    • آتش
    • سایر
  5. 5.

    چه اتفاقی افتاد؟ *

    (Long text)
  6. 6.

    اگر تبدیل به حادثه می‌شد، شدتش چقدر بود؟ *

    (Single choice)
    • جزئی
    • متوسط
    • شدید
    • مرگبار
  7. 7.

    به نظر شما علت چه بود؟

    (Long text)
  8. 8.

    پیشنهاد پیشگیری

    (Long text)
  9. 9.

    عکس محل

    (File upload)
  10. 10.

    موقعیت روی نقشه

    (Map location)

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
Download WordDownload PDF

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 ناشناس شبه‌حادثه”.
  3. Change the questions as you like, publish the form and send the link.

Related Safety templates

All Safety templates