Title Page
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Name of the employee:
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Employee job role
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Managers Name
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Assessment completed by:
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Assessment Conducted on
Medical Questions
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How many weeks pregnant are you?
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Estimated due date?
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Is your pregnancy classed as high risk from a medical perspective?
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Have any other medical concerns been identified that we need to be aware of?
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Are you suffering from any pain or discomfort?
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Have you informed your Manager?
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Have the first aiders been informed?
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In the event of a medical emergency at work, who should we contact on your behalf?
Workplace Mobility
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Is your workstation and chair suitable for you (DSE)?
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Do any of your tasks or processes involve awkward twisting, stretching or reaching?
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Are you required to stand for periods of more than two hours without a break?
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Are you required to sit for periods of more than one hour without a break?
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Do you have any movement restrictions due to lack of space?
Manual Handling
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Does your job involve twisting, stooping or stretching to lift objects?
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Does your job involve the lifting, pushing or pulling of heavy loads?
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Does your job involve rapid repetitive lifting (even of lighter objects)?
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Does your job involve lifting objects that are difficult to grasp or awkward to hold?
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Do you lift objects that have to be held away from your body and transported to another location?
COSHH
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Do any of your tasks or processes involve working with COSHH items?
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Do any of the COSHH items pose an increased risk to the NEMs health?
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Have reasonable adjustments been made for the NEM to reduce exposure to chemicals that could pose a risk to their health?
Working at Height
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Do any of your tasks or processes involve working at height?
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Have reasonable adjustments been made for the NEM to reduce or eliminate the requirement to work at height?
Extreme Temperatures
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Are you exposed to temperatures that are uncomfortably cold (below 16ºC) or hot (above 27ºC)?
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Are you exposed to cold draughts even when the average temperature is acceptable?
Work Hours
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Are you expected to regularly work long hours or overtime?
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Do you have flexibility or choice over your working hours if required?
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Do your shift patterns involve early starts or late finishes?
Work-Related Stress
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Are any of your tasks or processes known to be particularly stressful?
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Do your colleagues and managers provide you with adequate support?
Work-Related Violence
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Do you, or have you, experienced work-related violence as part of your job?
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Do you know what to do if you are the victim of work-related violence?
Worker Welfare
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Do you know where the welfare room is located?
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The welfare room is located on the 6th floor, on the right behind the kitchenette in the executive suite area.
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Do you have easy access to the facilities?
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Are you suffering from morning sickness?
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Does the morning sickness affect your ability to work?
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Are you having issues with attending medical appointments?
Summary
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Do you feel that you need additional support at this time?
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Next Assessment Date:
