Section 1 Mothers Details

1. NEW MOTHER'S DETAILS

Name

Date of Child's Birth

Job Title

Department

Line Manager

Hours Worked per Week

Work Description

Person carrying out Assessment

2. HAZARDS & WORKING CONDITIONS

Access to welfare facilities

Accompanied

Bending

Biological Agents

Carrying

Chemicals

Cold

Confined Spaces

Difficult Access / Egress

Driving

Excessive Movement

Heat

Lifting

Section 2 Hazards & Working Conditions

2. HAZARDS & WORKING CONDITIONS CONTINUED

Mental Fatigue

Moving Around College

Night Work

Noise

Overtime

Physical Fatigue

PPE

Queueing

Radiation

Shift Work

Shocks/Jolts

Sitting

Standing

Stretching

Vibration

VDU's

Walking

Working Alone

Working at Height

Section 3 Medical Conditions

3. OTHER

Are you currently breast feeding?

Access to suitable rest facilities available?

Access to privacy available?

Are there any pregnancy related medical conditions that we should be aware of? Please detail:-

Are there any other hazards that should be considered during this assessment? Please detail:-

4. COMPLETION & NOTIFICATION

New Mother advised of HSE link:- http://www.hse.gov.uk/mothers

Others Notified

Assessment completed by

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.