PROTECTION OF PREGNANCY, POST-NATAL AND BREASTFEEDING EMPLOYEES
[Safety, Health and Welfare at Work (General Application) Regulations, 2007]
N.B. This form should be completed by the employer in consultation with the employee.
Assessors Name (Print):Signature of Assessor:
Assessors Job Title:
Name of Pregnant Employee:
Due Date:
Date of Assessment:
Overall priority for remedial action
(on completion of Risk Assessment)
HOW TO COMPLETE THE RISK ASSESSMENT FORM
Indicate if the following risks are present by answering ‘YES’ or ‘NO’
For any identified risks (those you answer ‘YES’ to), elaborate as indicated in the right hand column
ARE ANY OF THE FOLLOWING RISKS PRESENT? / YES / NO / INDICATE
(1) the degree of risk present (high, medium or low, and
(2) proposed control measures
1.0 PHYSICAL AGENTS
1.1 / Manual Handling / HighMedium Low
Control Measures:
ARE ANY OF THE FOLLOWING RISKS PRESENT? / YES / NO / INDICATE
(1) the degree of risk present (high, medium or low, and
(2) proposed control measures
1.2 / Challenging Behaviour – Physical Injury / HighMedium Low
Control Measures:
1.3 / Extremes of heat or cold? / HighMedium Low
Control Measures:
1.6 / Noise? / HighMedium Low
Control Measures:
ARE ANY OF THE FOLLOWING RISKS PRESENT? / YES / NO / INDICATE
(1) the degree of risk present (high, medium or low, and
(2) proposed control measures
2.0 ERGONOMIC
If ‘YES’ is answered to Question 2.1, a full ergonomic workstation assessment is indicated, if one has not previously been carried out contact the Health and Safety Officer.
2.1 / Does the employee spend more than 1 hour per day or 8 hours per week at a computer workstation? / HighMedium Low
Control Measures:
3.0 FATIGUE AND MOVEMENT
3.1 / Fatigue from standing? / HighMedium Low
Control Measures:
ARE ANY OF THE FOLLOWING RISKS PRESENT? / YES / NO / INDICATE
(1) the degree of risk present (high, medium or low, and
(2) proposed control measures
3.2 / Fatigue from physical work? / HighMedium Low
Control Measures:
3.4 / Working in tight fitting spaces? / HighMedium Low
Control Measures:
3.5 / Moving vehicles or transport? / HighMedium Low
Control Measures:
ARE ANY OF THE FOLLOWING RISKS PRESENT? / YES / NO / INDICATE
(1) the degree of risk present (high, medium or low, and
(2) proposed control measures
3.6 / Working at heights? / HighMedium Low
Control Measures:
4.0 BIOLOGICAL AGENTS
Groups 2, 3 and 4 (Rubella, Chickenpox, Hepatitis, HIV, TB, Salmonella, E Coli)
4.1 / Presence of biological agents? / High Medium Low
Control Measures:
5.0 CHEMICAL AGENTS
(This section is not applicable to Western Care Association staff and has been omitted from this form).
ARE ANY OF THE FOLLOWING RISKS PRESENT? / YES / NO / INDICATE
(1) the degree of risk present (high, medium or low, and
(2) proposed control measures
6.0 OTHER FACTORS IN WORK/HUMAN FACTORS:
6.1 / Excessive mental pressure/stress/psychological effects or challenging behaviour? / HighMedium Low
Control Measures:
6.2 / Shift Work (early or night shift)? / HighMedium Low
Control Measures:
6.3 / Exposure to nauseating smells? / HighMedium Low
Control Measures:
ARE ANY OF THE FOLLOWING RISKS PRESENT? / YES / NO / INDICATE
(1) the degree of risk present (high, medium or low, and
(2) proposed control measures
6.4 / Difficulty in leaving job/site of work? / HighMedium Low
Control Measures:
6.5 / Use of protective clothing? / HighMedium Low
Control Measures:
6.6 / Overtime? / HighMedium Low
Control Measures:
ARE ANY OF THE FOLLOWING RISKS PRESENT? / YES / NO / INDICATE
(1) the degree of risk present (high, medium or low, and
(2) proposed control measures
6.7 / Evening Work? / HighMedium Low
Control Measures:
7.0 OTHER COMMENTS
8.0 TO BE COMPLETED BY THE EMPLOYEE:
I am satisfied that I have discussed the contents of this form with my manager and fully understand the details within and I undertake to inform him/her of any changes which could necessitate a review of this document.
SIGNED: ______
(Employee)