Return to Work Risk Assessment Form Template

• Employee Name

• Conducted on

  Date

• Prepared by

• Location
  Address

• Identify the hazards that are high priority and complete the fields accordingly. You can assign actions to responsible individuals via this form. You should review your risk assessment if you think it might no longer be valid.

About the Employee

• Job Title

• Department

• Location of Work

• Next Assessment Due

  Date

Risk Assessment

Hazard

• Describe the hazard

• Who might be harmed and how?

• What are you already doing?

• What can you still do to control its risk?

• Action Item Owner

• Action by When?

  Date

• Completed?

  Yes

  No

  N/A