Pregnancy Risk Assessment

Information provided by you via this online risk assessment is automatically forwarded to the Health & Safety Office

Name

Phone Number

Job Title

Email

Campus and Room Number

Name and Address of Doctor

Has your pregnancy been confirmed by a doctor?

Yes

No

Expected Date of Delivery

Have you notified your manager?

Yes

No

Managers Name

Work Environment - General

NIght work - do you work between 10pm and 6am?

Yes

No

Do you work alone?

Yes

No

Have you completed DCU Out of Hours training?

Yes

No

Are you aware of how to summon First Aid assistance?

Yes

No

Are you likely to encounter aggressive or violent persons?

Yes

No

Work Environment - Physical

Does your work activity involve exposure to the following?

Pressurised enclosures

Movement, travelling or postures that are abrupt or severe or give rise to excessive fatigue

Ionising Radiation

Cold Environment

Hot Environment

Non-Ionising Radiation

Confined Spaces

Vibration of Physical Shocks

Excessive Noise

Underwater Diving

Are you required to wear PPE while working?

Yes

No

If "Yes" list PPE provided:

Work Environment - Biological Agents

Is there likely exposure to biological agents which can endanger human health (Groups 2,3 or 4 biological agents)?

Yes

No

If "No" proceed to The Working Environment - Chemical Agents

Is there possible exposure to:

Toxoplasmosis

Rubella

Work Environment - Chemical Agents

If you do not work with chemical agents skip to next section.

R40: Limited evidence of a carcinogenic effect

Yes

No

H350/H351/R45: May cause cancer/suspected of causing cancer

Yes

No

H340/H341/R46: May cause genetic defects/suspected of causing genetic effects

Yes

No

H350i/R49: May cause cancer by inhalation

Yes

No

H360/ H360D/ H360FD/ H360Fd/ H360Df/ H361/ H361d/ H361fd/ R61 / R63: May damage fertility or the unborn child/ suspected of damaging fertility or the unborn child

Yes

No

If you do not work with Chemicals go to next section

H362/ R64: May cause harm to breastfed children

Yes

No

H370: Causes damages to organs

Yes

No

H371: May cause damage to organs

Yes

No

R68: Possible risk of irreversible effects

Yes

No

Mercury or mercury derivaties?

Yes

No

Antimitotic (Cytotoxic) drugs?

Yes

No

Carbon monoxide?

Yes

No

Lead or lead derivaties?

Yes

No

Chemical agents of known dangerous percutaneous (skin) absorption?

Yes

No

If "Yes" please list each chemical in use and its specified hazard statement

Chemical Name 1

Chemical Name 2

Chemical Name 3

Chemical Name 4

Chemical Name 5

Work Environment - Visual Display Units

Are you a Visual Display User (VDU)?

Yes

No

Have you completed the web based VDU Risk Assessment on your workstation?

Yes

No

Have you been provided with information on the safe use of VDUs?

Yes

No

Does your work involve long periods of time sitting or standing?

Yes

No

Are there constraints preventing good posture?

Yes

No

Can you vary tasks at your own discretion?

Yes

No

Is entry to tightly fitting workspaces required which would present comfort difficulties?

Yes

No

Is it necessary to reach over and around obstacles?

Yes

No

Is there any difficulty evacuating the building in an emergency due to lack of speed and movement?

Yes

No

Is there any difficulty wearing PPE due to increased size as the pregnancy develops?

Yes

No

Is the lighting adequate in your work area?

Yes

No

Do you use ladders/platforms at height?

Yes

No

Please not any particular concerns relating to pregnancy and your work?

Do you wish the H&S Office to contact you regarding specific safety issues in pregnancy?

Yes

No

Submit