Pregnancy Risk Assessment Template Form
	
Notes:	This template will assist employers in carrying out a risk assessment required by the Protection of Pregnant, Post Natal and Breastfeeding Employees Regulations 2007. 
In these regulations, an employee means a pregnant employee, an employee who is breastfeeding or a post-natal employee. 
On being informed that an employee is pregnant, you must carry out an assessment to consider if there are specific risks from the work to the employee and decide if any action needs to be taken to protect against something that could damage her health or that of her developing child. The existing workplace risk assessments should be available and may need to be examined whilst completing the individual risk assessment for the employee. 
There is no prescribed form that must be used to record the assessment but the following has been made available to aid employers.
For more information, the following guides and specific hazard control information are available on the HSA website:
Workplace Health Toolkit to Assist Small Business Section 6 
Guide to the General Application Regulations: Pregnant, Post Natal and Breastfeeding Employees	
Section 1:			EMPLOYEE RISK ASSESSMENT	
Name:		
Date:		
Company Address:		
Location:		
Job Title:		
Assessment Carried Out By:		
Manager / Supervisor’s Name:		
Name & Address of Medical Advisor:		
Number of weeks pregnant:		
Expected Date of Delivery:		
Employee’s Signature:		
Has the employee formally notified her employer that she is pregnant or is a new mother within 6 months and/or is breastfeeding?	Yes [    ] No [    ]
To Whom: _________________________
Date: ___________________	

Section 2:	
Physical Agents	Yes	No	Comments	
Does the  employee’s work activities involve exposure to the following:	
Physical shocks (including direct blows to the abdomen) or vibration to the body?				
Handling of loads entailing risks?				
Climbing steps, ladders or other heights?				
Excessive noise?				
Ionising or non-ionising radiation?				
Extremes of cold or heat?				
Movement, travelling or postures that are abrupt or severe or give rise to excessive fatigue?				
Underground mine work?				
Confined spaces?				
Within pressurisation chambers?				
Underwater diving?				
Biological Agents 	Yes	No	Comments	
Is there likely exposure to biological agents which can endanger human health (Groups 2, 3 or 4 biological agents)?				
Are control measures in place and personal protective equipment (PPE) provided if required?				
Is there possible exposure to:
Toxoplasmosis?
Rubella virus?
Has the employee immunity to such agents?				
Chemical Agents Hazards	Yes	No	Comments	
Do the employee’s work activities involve exposure to the following chemical agents? :		
Those labelled as the following? :
H350 / H351 : May cause cancer / suspected of causing cancer

H340 / H341 : May cause genetic defects / suspected of causing genetic effects

H350i : May cause cancer by inhalation

H360 /  H360D /  H360FD / H360FD / H360Df /  H361 / H361d / H361fd / H361d : May damage fertility or the unborn child /  Suspected of damaging fertility or the unborn child

H362 : May cause harm to breastfed children

H370 : Causes damage to organs 
H371: May cause damage to organs				
Mercury or mercury derivatives?				
Antimitotic (cytotoxic) drugs?				
Carbon Monoxide?				
Chemical agents of known dangerous percutaneous (skin) absorption?				
Lead or lead derivatives?				
Are control measures in place and PPE provided if required?				
Night Work	Yes	No	Comments	
Does the employee work at least three hours between 11pm and 6am?				
Does she have a medical certificate stating that night work should be avoided?				
Movement / Posture	Yes	No	Comments	
Does the work involve long periods of time sitting or standing?
Is there a chair accessible?				
Is the employee a visual display user (VDU)?
Has a workstation assessment been carried out?
Can the employee vary tasks at her own discretion?				
Is it necessary to reach over and around obstacles?				
Are there constraints preventing good posture?				
Is there exposure to strong air movements?				
Poor lighting?				
Use of ladders / platforms at height?				
Lone working? 
Is the employee aware of emergency procedures and has a means of communication?				
Aggressive or violent persons?
Is the employee trained how to deal with aggressive or violent persons?				
Is there any difficulty for the employee wearing PPE due to her increased size as the pregnancy develops?				
Entry to tightly fitting workspaces which would present comfort difficulties to the employee?				
Is there any difficulty in the employee evacuating the building in an emergency due to lack of speed and movement?				
Have you identified any other safety and health hazards? 	Yes	No	Comments	

				

Section 3: Risk Assessment Recommendations:	

	
The risk assessment is to be reviewed on a regular basis throughout the pregnancy or more frequently should circumstances dictate.