Title Page
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Document No.
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Conducted on
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Employee Name
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Client / Site
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Location
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How long has the member of staff had epilepsy?
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Has their symptoms become more severe in recent weeks or months?
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What medication do they take?
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Is there medication preventative or reactionary?
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If the Medication is reactionary, how quick will they need it in the event of a seizure
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Where is the medication stored? (Consider if it needs to be chilled, how accessible it is, how secure it is)
- At Home (not needed when in work)
- In Locker
- In fridge
- Other (please state)
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How frequent have seisures occurred in the last two years?
- More than Weekly
- Weekly
- Fortnightly
- Monthly
- Between 2 & 11 a year
- Once a year or less
- Never had a seisure
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Are there any pre-symptoms of seisures (Please put details below)
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What shifts are the person doing?
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Is there epilepsy light sensitive?
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Have they informed manager of what to do in the event of a seizure, both during and recovery
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Any other information we need to be aware of
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Signed Member of Staff
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Signed Risk Manager
