Title Page
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Document No (ddmmyyinitials).
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Conducted on
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Assessment Carried out By
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Office / Factory Location
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Name of New or Expectant Mother
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Job Title
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Manager/Supervisor details
General
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Emergency Contact details (phone no)
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Have you informed the Company in writing of your condition?
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Has there been a risk assessment conducted previously?
COSHH /Chemicals
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Do you use any chemicals or substances including toner? Y/N Details
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Can these substances be safely used?
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Is a COSHH assessment required?
Display Screen Equipment and Work Space
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Has a DSE assessment been carried out?
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Is there enough room?
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Do you require a footrest?
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Are there any trailing cables or other obstacles in the work area?
Working Environment
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Are there any issues in respect of, temperature, humidity, lighting or noise within your work area?
Fire, First Aid and Emergency
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Has the fire marshal been made aware of your condition?
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Have the first aiders been made aware of your condition?
Manual Handling
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Are there any aspects of your job that require you to undertake any form of manual handling?
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Is a separate manual handling assessment required?
Well Being
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Do you have access to suitable rest areas to sit or lie down?
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Are you experiencing any ailments related to your condition?
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How are you feeling in general?
Working Pattern
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What are your working hours and are you coping with them?
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How are you coping with the work that you do?
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How are you coping with the normal pressure of your work?
General #2
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Assessment carried out by?
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Date Assessment completed
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Assessment to be shared with Peoplelink
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Assessment to be shared with Manager
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Assessment to be shared with New or Expectant Mother?
