Employee Medical Condition Workplace Risk Assessment
Assess the impact of an employee's medical condition on workplace safety and identify necessary accommodations.
Employee Full Name
*
First Name
Last Name
Employee ID Number (last 4 digits only)
*
Job Title / Position
*
Department / Work Area
*
Supervisor or Manager Name
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Describe the employee's medical condition (do not include diagnosis codes or sensitive information)
*
Does the medical condition affect the employee's ability to perform essential job functions?
*
No impact
Minor impact
Moderate impact
Severe impact
Not sure
Workplace Risk Assessment Table
*
Rows
Likelihood of Exposure
Severity if Incident Occurs
Current Controls Adequate?
Physical hazards (machinery, equipment)
1
2
3
Chemical exposure
4
5
6
Biological exposure (germs, infection)
7
8
9
Workplace stressors
10
11
12
Other (specify in comments)
13
14
15
Recommendations for accommodations or actions to reduce risk
*
Additional comments or notes
Submit Assessment
Should be Empty: