Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • What is the current condition the employee is suffering from? (e.g. Broken leg, broken ankle, etc)

  • List the current symptoms of condition (e.g. pain in injury, unable to bear weight, using crutches, etc)

  • List current medication and any side effects the employee is currently experiencing (e.g. painkillers (specify which), and any side effects this may cause)

  • Does the employee stand for long periods?

  • If yes to above advise employee to make sure they sit down as often as they feel it necessary and to take their designated breaks.

  • Is employee able to use ladders? (If employee is unable to bear weight on each limb or unable to have 3 points of contact on the ladder, then they are unable)

  • Should manual handling be limited?

  • If yes to above advise the employee they are only to lift loads that they fell comfortable lifting and to ask for help when needed.

  • Can employee use work equipment? (Pallet trucks/cages/vacuum cleaner)

  • Arrange a review date for next Risk Assessment

  • Has Risk Manager / Employee relations been briefed on necessary information relating to employees condition?

  • Please sign in the space provided

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.