Pregnancy risk assessment checklist
Donald russell
What does this form include?
This form contains 20 sections:
Answer all mandatory questions with a red line next to them
Has Donald Russell received written notification of pregnancy?
- Has Donald Russell received written notification of pregnancy?
Date received Date
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Have you had any specific advice from your doctor or midwife?
- Have you had any specific advice from your doctor or midwife?
MAT B1 form required after 20 weeks of pregnancy from:
- MAT B1 form required after 20 weeks of pregnancy from:
Date required Date
1 - PHYSICAL JOB DEMANDS - Does the work involve?
- Lifting or pushing heavy objects?
- Standing for long periods?
- A Lot of Walking?
- Work at height or climbing steep steps?
- Will any task become more hazardous due to expectant mothers changing shape or size?
- Is shift / lone working required?
2 - MENTAL JOB DEMANDS - Does the work?
- Require the expectant mother to meet challenging deadlines?
- Involve rapidly changing demands and priorities?
3 - GENERAL WORKING CONDITIONS
- Require a high degree of concentration?
- Do any relevant risk assessments (including DSE) need to be reviewed?
Is there any exposure to any of the following?
4 - SPECIFIC HAZARDS - Will the expectant mother be exposed to?
- Will Personal Protective Equipment (PPE) present a problem as the Pregnancy develops?
Is there a need for business travel (select all possible modes of travel)
6 - OUTPUT RESULTS FROM ABOVE RISK ASSESSMENT
- Is a referral to Occupational Health required (if applicable based on output of Risk Assessment)?
****Assessment to be reviewed at request of employee or manager.
Recommendations & Comments
***I can confirm I have read and understood the above document. I can also confirm that if I experien
Expectant Mother Sign
***I will ensure that the expectant mother named above will be allowed to heed the above advice as ap
Line Manager Sign
Use this template