Pregnancy Workplace Risk Assessment Form
Help us ensure your health and safety at work by providing details about your pregnancy and your working environment.
Employee Full Name
*
First Name
Last Name
Job Title
*
Department/Work Area
*
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Expected Due Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate your current stage of pregnancy
*
Please Select
First trimester (1-12 weeks)
Second trimester (13-26 weeks)
Third trimester (27+ weeks)
Workplace Risk Assessment Matrix
*
Rows
Not Exposed
Occasionally Exposed
Frequently Exposed
Prolonged standing
1
2
3
Heavy lifting or carrying
4
5
6
Exposure to chemicals
7
8
9
Exposure to infectious agents
10
11
12
Exposure to extreme temperatures
13
14
15
Workplace stress
16
17
18
Long working hours
19
20
21
Are you currently experiencing any health concerns related to your work?
*
Yes
No
Please provide details if you answered 'Yes' above
Have any adjustments been made to your work duties or environment due to your pregnancy?
*
Yes
No
If adjustments have been made, please describe them
Please provide any recommendations or additional comments regarding your workplace safety during pregnancy
Submit Assessment
Should be Empty: