Download Pregnancy Risk Assessment Template

Expectant & Nursing
Mothers Risk
Assessment
NB:
If completing this form electronically, entries can only be made in the shaded areas. Shaded
rectangles will expand to fit the text entered. Clicking on a tick box will enter an “x” in the box
Name of Expectant / Nursing Mother:
School/Department:
Job title/course:
Brief description of duties:
Number of weeks pregnant (if known):
Assessor:
Date:
1. Physical Job Demands
Yes
No
Does the work involve:

Lifting or pushing heavy
objects?

Standing for long periods?

A lot of walking?

Work at height or climbing
steep steps?
Advice if yes
Do not lift heavy objects – ask
others to do this for you.
Ensure that you sit down as often as
you feel is necessary. If you do
stand for long periods have a chair
nearby.
Take regular rest stops and sit down
as often as is necessary.
Avoid working at height (for
example,
work
on
elevated
platforms). Use lifts instead of stairs
where possible.
Inform your line manager / tutor if
and when body shape becomes a
problem (for example, you cannot
get close enough to the task).
Night shifts and lone working should
be avoided.

Will any tasks become more
hazardous due to expectant
mother’s changing shape
and size?

Is shift work/lone working
required?
Other recommendations and comments:
2. Mental job demands
Yes
No
Does the work:

Require the expectant /
nursing mother to meet
challenging deadlines?

Involve rapidly changing
demands and priorities?

Require a high degree of
concentration?
Rev 03 Jan 017
Advice if yes
Inform your line manager / tutor
immediately if you feel workload is
too high and/or is causing stress.
Your line manager / tutor should
discuss this with you and take
appropriate action.
Page 1 of 5
Other recommendations and comments:
3. General Working Conditions
Yes
Is
any
relevant
DSE
assessment up to date?
No
risk
Does the work involve any home
working?
Are toilet facilities easily accessible
to the expectant mother?
Can the expectant / nursing mother
take
toilet
and
rest
breaks
immediately when necessary?
Can the expectant / nursing mother
control the pace of work?
Is
a
reasonable
temperature
maintained
in
the
working
environment?
Is there sufficient room for the
expectant mother to gain access
and egress to and from workstation
(consider
expectant
mother’s
changing shape and size)?
Does the expectant / nursing
mother have a suitable, adjustable
chair?
If your job entails desk work your
chair should conform to DSE
standards. If you do not normally
sit to undertake your work, a chair
should be available for you to rest
as necessary.
Any control measures required
additional to those already in place
should be listed below.
Please
remember that these may have to
be reconsidered in the later stages
of pregnancy.
In the later stages of pregnancy
your mobility will be reduced as will
your
ability
to
respond
to
emergencies.
Your emergency
duties
might
need
to
be
reconsidered at this time.
Is there a risk of violence?
Does the work or additional duties
involve dealing with emergencies?
Other recommendations and comments:
Rev 03 Jan 017
General Advice
DSE risk assessment should be
reviewed annually or following a
significant
change
to
the
workstation
Ensure that your home working
environment is comfortable and that
the same display screen equipment
use practices are observed as would
be in work.
Toilet facilities should be suitably
close to allow you to take toilet
breaks as often as necessary.
Please take toilet and rest breaks as
necessary. First Aid rooms may be
used by expectant mothers to take
rest breaks.
If the pace of work is causing stress
please consult your line manager /
tutor who should discuss this with
you and take appropriate action.
Please report any uncomfortable
temperatures to your line manager /
tutor
Inform your line manager as soon
as body shape becomes a problem
so that remedial action can be
taken.
Page 2 of 5
4.Specific Hazards
Yes
No
Will the expectant / nursing mother
have potential exposure to:

Harmful substances
Substances
with
greater
risk
potential are those with the
following hazard statements:
Consult suppliers’ Safety Data
Sheets (SDS) and RGU COSHH
assessments where applicable.
If relevant hazard statements are
identified,
please
consult
Occupational
Health
and
Environmental Safety department
(OHES) as soon as possible for
specific
advice
[email protected]
H340
May
cause
genetic
defects
H341 Suspected
of
causing
genetic defects
H350 May cause cancer
H351 Suspected
of
causing
cancer
H360 May damage fertility or
the unborn child
H361 Suspected of damaging
fertility or the unborn
child
H362 May cause
harm to
breast-fed children

Fumes, Smoke, Dust
Any exposures to fumes, smoke or
dusts arising from substances
identified
above
may
present
greater risk potential.
Consult suppliers’ Safety Data
Sheets (SDS) and RGU COSHH
assessments where applicable.
If relevant hazard statements are
identified, please consult the OHES
department as soon as possible for
specific advice.

Whole-Body Vibration
Whole-body vibration (WBV) comes
from driving a vehicle over rough
terrain. Continued exposure to
vibration, or sudden shocks, e.g.
driving over a tree stump, can lead
to
back
pain
and
other
musculoskeletal disorders.
Check equipment manufacturer’s
manual and identify any risk of
whole-body vibration exposure >0.5
m/s2 A(8). Avoid significant wholebody vibration exposures. Consult
OHES if in doubt.

Ionising
radiation
practices
A “practice” means work involving (a)
the
production,
processing,
handling, use, holding, storage,
transport or
disposal of radioactive substances;
or
(b)
the operation of any electrical
equipment
emitting
ionising
radiation
and
containing
components operating at a potential
difference of more than 5kV, i.e. XRay equipment
Rev 03 Jan 017
Advice if yes
Please consult the OHES department
as soon as possible for specific
advice.
Page 3 of 5

Electromagnetic Fields
Sources of electromagnetic (EMF)
energy that require consideration
during pregnancy are:
Please consult OHES department as
soon as possible for specific advice.
Broadcast
and
telecoms
base
stations,
inside
operator’s
designated exclusion zone
Radio frequency or microwave
energised lighting equipment
Radio and TV broadcasting systems
and devices
Work in close proximity to cables
carrying high currents (>100A)
Automated
induction
heating
systems: fault-finding and repair
involving close proximity to the EMF
source
Dielectric heating and welding
Resistance welding: manual spot
and seam welding
Induction heating
Induction soldering
Magnetic particle inspection (crack
detection)
Industrial
magnetiser
and
demagnetisers, e.g. tape erasers
Microwave heating and drying
RF
plasma
devices
including
vacuum deposition and sputtering
Automated welding systems, faultfinding:
repair
and
teaching
involving close proximity to the EMF
source
Diathermy
Transcranial Magnetic Stimulation
Medical MRI / NMR equipment
Radar - air traffic control, weather
and long range

Personal
Protective
Equipment
If the expectant / nursing mother
requires
personal
protective
equipment (PPE) will this present a
problem
as
the
pregnancy
develops?
Rev 03 Jan 017
If
PPE
becomes
restrictive,
uncomfortable or cannot be worn
due to body shape then do not
undertake the task for which the
PPE is required.
Page 4 of 5

Travel
Is the expectant / nursing mother
required to travel on business by:

Road

Rail

Air

Sea
If undertaking a long journey please
ensure you allow enough time for
rest breaks.
Walk up and down aisles as
necessary.
Please consult your GP and travel
agent before booking travel.
Please consult your GP and travel
agent before booking travel.
In general – long distance business
related journeys should be avoided,
wherever possible, in the later
stages of pregnancy.
Other recommendations and comments:
5. General Comments
I confirm that I have read and understood the above:
...................................................... Expectant / nursing mother
(signed)
...................... Date
I will ensure that expectant / nursing mother named above will be allowed to heed the above
advice as appropriate. In addition, I will ensure that the above noted recommendations are
implemented as appropriate and will continue for as long as is necessary.
...................................................... Line manager / Tutor
(signed)
...................... Date
Copies of this form should be retained by the expectant /nursing mother, the line manager / tutor
and the HR Department.
Further information:
Guidance for Use of Facilities for Breastfeeding
Rev 03 Jan 017
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