Kermit Thomas

Injury Risk Assessment Tool

Can be used during an employee's first 100 days or as needed.

Use this Template

Print as PDF

Use this Template

Go digital today!

Convert your paper checklists into digital forms

Scan this QR code to use this paper checklist on your smartphone or tablet or visit https://safetyculture.com/

INITIAL SCORE

Name and Job Title
Conducted on
Prepared by
Department name or Group home?
Job Experience
Employment History
Accommodations needed?
Injury Risk Factor; greater than or equal to 5 requires explanation.

ADJUSTED SCORE - after 100 days completed by safety coordinator/supervisors/QA

Conducted on
Prepared by
Explanation for adjusted score
Adjusted Injury Risk Factor
Name/Position
Name/Position
Name/Position

Results distributed to employee, supervisor and program director

Kermit Thomas

Injury Risk Assessment Tool

Can be used during an employee's first 100 days or as needed.

Use this Template

Print as PDF

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.