PREGNANCY HEALTH AND SAFETY CHECKLIST
Employee Name___________________ Unit_______________________
Date of Risk Assessment _____________Date Of Review______________
1) 1. Physical job demands ...............................................................................................................Y
N
a) •Does the work involve lifting or pushing heavy objects? ....................................•
•
b) •Does the work involve standing or squatting for long periods? ..........................•
•
c) •Does the role involve a lot of walking? ...............................................................•
•
d) •Does the work involve working at height or climbing steep steps? ....................•
•
e) •Does the employee need to access areas with limited space? .............................•
•
f) •Will any tasks be more hazardous as the employee changes shape and size? .....•
•
g) •Does the role involve shift work? ........................................................................•
•
h) •If so, does it involve working at night? ...............................................................•
•
2) Mental job demands
a) •Does the job involve meeting challenging deadlines? .........................................•
•
b) •Does the role involve rapidly changing priorities and demands? ........................•
•
c) •Does the role require a high degree of concentration? ........................................•
•
3) Working conditions - general
a) •Does the work involve lone working or working in remote locations? ...............•
•
b) •Are toilet facilities easily accessible to a pregnant worker? ................................•
•
c) •Is the worker able to take toilet breaks when necessary? ....................................•
•
d) •Can the worker take rest breaks when needed? ...................................................•
•
e) •Can the worker control the pace of her work? .....................................................•
•
f) •Are there any risks of violence at work? .............................................................•
•
g) •Does any part of the job involve dealing with members of the public? ..............•
•
h) •If so, does it involve dealing with distressed or disturbed people? .....................•
•
i) Does the role involve:
i) - Contact with young children or sick people? ................................................•
•
ii) - Unpredictable working hours? ......................................................................•
•
iii) - Dealing with emergencies? ...........................................................................•
•
j) •Are there any obstacles in corridors or offices that could cause problems
for pregnant women, e.g. in the event of a fire evacuation? .................................•
•
k) •Is the workplace non-smoking? ...........................................................................•
•
l) •If not, is the worker separated from any designated smoking area? ....................•
•
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m) •Is there any other form of indoor air pollution? ..................................................•
•
n) •Is the temperature in her working environment reasonable? ...............................•
•
o) •Is there enough room for the worker to get in and out of her workstation? ........•
•
p) •Will there be enough room as the pregnancy develops? .....................................•
•
q) •Does the worker have an adjustable seat, with a backrest? .................................•
•
4) Specific hazards
a) •Does any part of the job involve the use of chemicals? ......................................•
•
b) •If so, are there any risks to the employee whilst she is pregnant or
a nursing mother? ..................................................................................................•
•
c) •Is there any exposure to vibration, e.g. through the use of hand tools? ...............•
•
d) •Does the employee need to wear personal protective clothing? ..........................•
•
e) •If so, will this present a problem as the pregnancy develops? .............................•
•
Action needed to maintain Safety
Checklist to be completed by pregnant employee with senior staff member (At least care
supervisor level.)
Once checklist is completed control document overleaf should be completed by senior staff
member and shared with employee.
This checklist has been completed to the best of my knowledge.
Signed: ....................................................
Date: ........................................................................
Signed by Senior Staff Member: .............
Date: ........................................................................
Note: This checklist is to be kept on file for at least three years.
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PREGNANCY HEALTH AND SAFETY CONTROLS
1) Please enter code above under “Identified Hazard” for any areas that have the “Yes”
box ticked
2) Circle High Medium or Low under risk.
3) Document actions needed to reduce risk under Controls for any hazards that present
a high or medium risk.
Identified
Hazard
Risk.
Control
H M L
H M L
H M L
H M L
H M L
H M L
H M L
H M L
H M L
H M L
H M L
H M L
H M L
H M L
This assessment has been completed to the best of my knowledge.
Signed: ....................................................
Date: ........................................................................
Signed by Senior Staff Member: .............
Date: ........................................................................
Note: This assessment is to be kept on file for at least three years.
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