Pregnancy Risk Assessment

• Pregnant worker name

• Conducted on

  Date

• Prepared by

• Line Manager

• Role

• Duties in Brief

• Due Date

  Date

Past History / Pre-existing conditions

• Is this your first pregnancy?

  Yes

  No

  N/A

• How many children do you have?

• Did you have any issues during your last pregnancy?

  Yes

  No

  N/A

• What were the issues

• Do you have any pre-existing medical issues

  Yes

  No

  N/A

• What conditions do you suffer with?

Personal

• Do you suffer from morning sickness?

  Yes

  No

  N/A

• How often do you suffer from this?

• Are you suffering from fatigue?

  Yes

  No

  N/A

• In what way do you suffer from this?

• Are you up to date with inoculations?

  Yes

  No

  N/A

• Do you suffer from any allergies?

  Yes

  No

  N/A

• Please state allergies

Job Demands

• Lifting or pushing heavy objects?

  Yes

  No

  N/A

• Advise employee to avoid manual handling activities, use mechanical aids/colleague support, reduce load to less than 5kg.

• Action to be taken

  Yes

  No

  N/A

• Standing for long periods?

  Yes

  No

  N/A

• Advise employee to make sure they sit down as often as they feel is necessary. If they do stand for long periods, have a chair nearby.

• Action to be taken

• Work at height or climbing steep steps?

  Yes

  No

  N/A

• Advise employee to avoid working at height (e.g. Work on elevated platforms) Use lifts instead of stairs where possible.

• Action to be taken

• Will any task become more hazardous due to expectant mothers changing shape or size?

  Yes

  No

  N/A

• Advise employee to inform their line manager if and when body shape becomes a problem (I.e. They cannot get close enough to the task)

• Action to be taken

• Is lone working required?

  Yes

  No

  N/A

• What works will be conducted?

• Is posture and movement an issue?

  Yes

  No

  N/A

• What adjustments would you like to see?

Working Environment

• Is the temperature in the workplace an issue?

  Yes

  No

  N/A

• How is this an issue?

• Are toilet facilities easily accessible?

  Yes

  No

  N/A

• Where is the closest toilet located?

• Can toilet breaks be taken immediately if needed?

  Yes

  No

  N/A

• Why is this a barrier?

• Is there adequate ventilation?

  Yes

  No

  N/A

Work station

• Does your DSE assessment need to be updated?

  Yes

  No

  N/A

• Direct to SmartLog to review DSE assessment (https://sl.safesmart.co.uk/auth/login)

• Why do you believe it needs updating?

• Do you have enough space to move around at your workstation

  Yes

  No

  N/A

• Explain why?

Working conditions

• How is your work load?

• Can you make any adjustments to your workload?

  Yes

  No

  N/A

• Why?

• Is your workload adding stress

  Yes

  No

  N/A

• Can you reduce workload?

  Yes

  No

  N/A

• What are your working hours?

• Are you in contact with hazardous materials?

  Yes

  No

  N/A

• What materials do you work with?

  Yes

  No

  N/A

Mental demands of job

• Are you suffering from high levels of stress?

  Yes

  No

  N/A

• Please explain

• What adjustments can be made

• Are you suffering from anxiety?

  Yes

  No

  N/A

• Please explain

• What adjustments can be made

Additional information offered by employee

• undefined

Output results from the above assessment

• Is a referral to Occupational Health required (if applicable based on output of Risk Assessment)?

  Yes

  No

  N/A

• If you feel the expectant mother is at risk in their role please request an appointment with Occupational Health through the HR department.

• Recommendations & Comments

• Date of next review

  Date

• To be reviewed every 3 months during pregnancy

Declaration

• ***I can confirm I have read and understood the above document. I can also confirm that if I experience any issues at all such as discomfort, pain etc. I will inform my Line Manager immediately.***

• Employee signature

  Sign

• ***I will ensure that the expectant mother named above will be allowed to heed the above advice as appropriate. In addition, I will ensure that the above noted recommendations are implemented as appropriate and will continue for as long as is possible, however will need to be managed and monitored in line with the needs of the business.***

• Health and Safety Officer Signature

  Sign

• Any other witnesses to the assessment

  Yes

  No

  N/A

• Name

  Sign