Return to Work Risk Assessment

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


Location of Work

Next Assessment Due
Risk Assessment

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?


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.