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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