Pregnancy Risk Assessment Template Form This template will assist employers in carrying out a risk assessment required by the Protection of Notes: 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: RISK ASSESSMENT Section 1: EMPLOYEE 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 Yes [ ] No [ ] that she is pregnant or is a new mother within 6 To Whom: _________________________ months and/or is breastfeeding? Date: ___________________
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: 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: ___________________
Pregnancy_Risk_Assessment_Template.docx