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New and Expectant Mothers Assessment Form

    Potential Risks

    Does the work involve significant manual handling operations?

    Does the work involve the use of hazardous chemicals and substances or exposure to infectious diseases/biological agents?

    Is the person required to work standing or sitting for long periods?

    Does the work involve operating hazardous machinery? (Note this may include machinery that is noisy or vibrating)

    Does the person work nights or shift work?

    Does the work involve working long hours?

    Does the work involve extremes of high and low temperatures?

    Does the work involve working alone?

    Does the work involve working at heights?

    Does the work involve travelling? (i.e. Driving)

    Does the work expose the person to a risk of violence?

    Are any pollutants (e.g. Cigarettes Smoke) present in the work environment?

    Is the work deemed demanding and stressful?

    Assessment Form

    You can add more hazards by checking the 'Add Another Hazard' box at the bottom of the form

    Hazard ref: 1

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    + Add: Add another Hazard

    Hazard ref: 2

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    Hazard ref: 4

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    Hazard ref: 5

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    Hazard ref: 6

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    Hazard ref: 7

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    Hazard ref: 8

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    Hazard ref: 9

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    Hazard ref: 10

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    Hazard ref: 11

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    Hazard ref: 12

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    Due (date):

    You cannot add any more items, please fill in another form

    Name :

    Date :

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