The assessors believe the information contained within this assessment report to be correct at the time of printing. The assessors do not accept responsibility for any consequences arising from the use of the information herein. The report is based on information which was supplied, observed or came to the attention of the assessor during the day of the assessment and should not be relied upon as an exhaustive record of all possible risks or hazards that may exist or potential improvements that can be made.
In order to maintain the integrity and credibility of the assessment processes and to protect the parties involved, it is understood that the assessor will not divulge to any unauthorized persons any information obtained during this assessment unless legally obligated to do so.
Full Name of Employee
Home Telephone Number (landline)
Mobile Telephone Number
Named Contact in the Event of an Emergency (1)
Telephone Number (1)
Relationship to You (1)
Named Contact in the Event of an Emergency (2)
Telephone Number (2)
Relationship to You (2)
What type of Epilepsy or Epilepsy Syndrome do you have?
How often do you have a seizure?
Have you experienced a seizure within the last week?
Have you experienced a seizure within the last month?
How many seizures have you had within the last year?
Have you had surgery for your Epilepsy? Include dates
Are you always aware when a seizure will occur? Are you able to prepare?
What happens to you in a seizure?
How long does your seizure normally last for?
How long does it take you to recover after a seizure?
What medication do you take to control your Epilepsy?
Name of medicine / strength / taken how many times per day / at what time per day ?
What to do if your seizure lasts longer than _____ minutes? Use this to give instructions to others on what they should do if your seizure lasts longer than _____ minutes.
Planned location where the seizure should preferably take place in the workplace
Room conditions? consider privacy, light, floor space, loose objects in the room, room risk assessment, comfortable mat, supervision, medication, person to time the seizure, availability of care plan?
Will a trained first aider be required and available to care for you during a seizure?
Should emergency Medication be given?
State dose and when to give emergency medication, after _____ minutes
Can a second dose of medication be given if the first dose fails to work?
State dose of medication and when to give medication after the first dose
How is the medication to be given?
Does your medication need to be taken with food / water / after or before food?
Is there anything that makes your seizures more likely?
Is there anything you to do in your day to day life to manage your epilepsy and your safety?
Does a named contact need to be contacted after a seizure?
Do you feel your colleagues need to be aware that you have epilepsy? This is your personal choice and there is no need for you to do so should you choose not to unless there is a risk to others
Do you need additional rest breaks throughout the day?
Do you require or feel your employer could make any reasonable adjustments?
Do you require a buddy or designated member of staff to accompany you during a seizure?
What can trigger your epilepsy and what control measures are in place?
Name and Address of Doctor
Does your Dr need to be informed of any seizure?
Location of the care plan
Overnight Accommodation Plan
Tiredness with travelling
Accompanied by First Aider
Location of medication
Are off site risk assessments in place for visits off site?