Heat Stress Monitoring Form
Use this form to record heat exposure conditions, symptoms, hydration status, and any immediate actions so supervisors can monitor heat stress risk and respond quickly.
Worker and Shift Details
Worker name
*
First Name
Middle Name
Last Name
Job role or team
*
Date
*
-
Month
-
Day
Year
Date
Shift start time
*
Hour Minutes
AM
PM
AM/PM Option
Shift end time
*
Hour Minutes
AM
PM
AM/PM Option
Work location or site
*
Supervisor name
First Name
Middle Name
Last Name
Working environment
*
Indoors
Outdoors
Heat Exposure and Environment
Current Task or Activity
*
Please Select
Indoor work
Outdoor work
Vehicle operation
Material handling
Maintenance/repair
Construction
Other
Approximate Duration of Heat Exposure (hours)
*
Direct Sun Present?
*
Yes
No
Sometimes
Weather or Ambient Condition Estimate
*
Please Select
Cool
Warm
Hot
Very hot
Extreme heat
Access to Shade or Cooling
*
Full shade
Partial shade
Limited shade
No shade
Indoor cooling available
Cooling not available
Hydration Access
*
Adequate water access
Water available nearby
Limited water access
Cool drinking water available
Electrolyte drinks available
Other
Additional Environmental Hazards
Symptoms, Risk Checks, and Actions
Current heat-stress symptoms
*
Dizziness
Headache
Nausea
Heavy sweating
Cramps
Confusion
Fatigue
Rapid heartbeat
None
Symptom severity
*
None
Mild
Moderate
Severe
Needs a break or medical attention?
*
No
Yes
Immediate actions taken
Acknowledgment of heat-safety check and supervisor instructions
*
I acknowledge the heat-safety check and will follow the supervisor's instructions
I do not acknowledge
Submit
Should be Empty: