Lighting Flicker Risk Assessment Form
Lighting Flicker Risk Assessment Form – Use this form to evaluate flicker-related risks in lighting installations or workspaces.
Location / Site Identification
*
Lighting Type
*
Please Select
LED
Fluorescent
Incandescent
Halogen
Other
Observed Flicker Symptoms
*
Visible flicker
Eye strain
Headache
Discomfort
Other
Flicker Severity (How intense is the flicker?)
*
None
1
2
3
4
Severe
5
1 is None, 5 is Severe
Flicker Frequency (How often does flicker occur?)
*
Rarely
Occasionally
Frequently
Constantly
Likely Trigger Conditions
Switching on/off
Dimming
Equipment startup
Power fluctuations
Other
Affected Areas
*
Recent Changes in Lighting or Environment
Inspection Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Reviewer Notes, Overall Risk Rating, or Recommended Action
Submit Assessment
Should be Empty: