Form library · Health and safety
Pregnancy risk assessment template
For employers and assessors reviewing work with a pregnant worker. Record work and consultation, workplace factors and decision and review. Try the form below, see every question or download a blank PDF or Word copy.
Ready to use from the form library, and every question is yours to edit. Trial from £1, cancel any time.
Try it on your phone
Try it on this phone
Fill in the pregnancy workplace risk assessment on your phone now
See how the pregnancy workplace risk assessment looks on your phone
Scan the code with your phone camera. It opens the real form, no sign-up needed.
Open the live example and fill it in, just as your team would on site. No sign-up needed.
See it on this phoneEvery question is editable. Add this form to your account, then change the wording, add or remove questions and options, and make it fit your own jobs.
When is an individual assessment required?
HSE says employers must assess an individual worker’s risks after written notification of pregnancy, breastfeeding or giving birth in the previous six months. Discuss concerns, take account of medical recommendations, record findings and review as circumstances change. If risks cannot be controlled, HSE sets out adjustments, suitable alternative work and paid suspension in that order.
Last updated . Facts checked by the SiteSurvey team on 6 October 2026 against HSE individual risk assessment for pregnant workers and new mothers and ICO data protection principles.
Try the pregnancy workplace risk assessment form live
Answer a few questions and watch it adapt. Your answers are not saved, and any photos you add are deleted within the hour.
This is the real form as your team would use it: questions appear as you answer, scores work themselves out and you can add photos and signatures. No sign-up needed.
Want to see one filled in? See a completed pregnancy workplace risk assessment report (PDF), made by SiteSurvey from a fictional site visit.
Fill it in on a phone or tablet
Your team completes the pregnancy workplace risk assessment on site in the SiteSurvey app on iPhone, iPad and Android phones and tablets. The project name and address fill in for them, it works without signal, and it syncs when the device is back online with photos kept against the question they answer.
Customers and subcontractors do not need the app: send them a link and they can fill it in from any browser.
Every question in the pregnancy workplace risk assessment template
An individual workplace assessment recording job demands, consultation, pregnancy-related work adjustments, responsible people and review arrangements. 5 sections and 32 questions. Follow-up questions and guidance appear only when an answer calls for them, so the person on site never sees the ones that do not apply.
Make it your own: every question is editable
This is a starting point, not a fixed form. Once it is in your SiteSurvey account you can reword any question, add or remove questions, sections and answer options, and add your own logo, so it fits the way your team works and the jobs you do.
Details you only enter once
Add this form to a project in SiteSurvey and it fills in what the project already knows, so nobody on site retypes it and every form on the job uses the same names. Anything filled in can still be changed.
- Project: the project name
- Site or premises address: the site address, from the space or the project
- Client or organisation: the project's customer
Record details and scope
- ProjectShort answer
Filled in from the project in SiteSurvey.
Fills in from the project name - Site or premises addressShort answerFills in from the site address, from the space or the project
- Client or organisationShort answerFills in from the project's customer
- Record date*Date
- Person completing the record*Short answer
- CheckThis records workplace controls, not a medical assessment. Record only necessary work restrictions and references, avoid clinical histories, and restrict access to personal information.
- CheckHSE says employers must assess an individual worker’s risks after written notification of pregnancy, breastfeeding or giving birth in the previous six months. Discuss concerns, take account of medical recommendations, record findings and review as circumstances change. If risks cannot be controlled, HSE sets out adjustments, suitable alternative work and paid suspension in that order.
Work and consultation
- Worker reference*Short answer
- Role, location and working pattern*Short answer
- Date of written notificationDate
- Consultation date*Date
- Work-related concerns raised without unnecessary medical detailNotes
- Relevant professional advice reference, held securelyShort answer
Workplace factors
- Work factorRepeat for each work factor. Each one asks:
- Factor*Choose one
- Physical demands
- Hours and fatigue
- Substances or infection
- Work environment
- Travel or lone work
- Other
- Task, exposure and potential harm*Notes
- Existing controls and further adjustments*Notes
- Responsible person*Short answer
Decision and review
- Agreed changes to conditions or hours*Notes
Record agreed changes to work and when their effectiveness will be reviewed. Keep unnecessary medical details out of the assessment.
- Uncontrolled risks and escalation to the employerNotes
- Alternative work or employment decision reference, if neededShort answer
- Next agreed review date*Date
- Changes that bring the review forwardNotes
- How findings were shared with the workerNotes
Actions and review
- Are further actions required?*Choose one
- Yes
- No
- Further actionRepeat for each further action. Each one asks:Shown when “Are further actions required?” is “Yes”
- Action and evidence reference*Notes
- Person responsible*Short answer
- Target dateDate
- Action status*Choose one
- Open
- In progress
- Completed
- Completion evidence*NotesShown when “Action status” is “Completed”
- Outstanding limitations and information to pass onNotes
- Record status*Choose one
- Ready for review
- Further work needed
- Work or use stopped
- Reviewed byShort answer
- Review dateDate
- Author signature*Signature
- CheckSigning records the information entered. It does not itself certify legal compliance, remove a limitation or authorise unsafe work.
Scope and responsibility
This records workplace controls, not a medical assessment. Record only necessary work restrictions and references, avoid clinical histories, and restrict access to personal information.
What a useful entry looks like
Agreed changes to conditions or hours
Record agreed changes to work and when their effectiveness will be reviewed. Keep unnecessary medical details out of the assessment.
Lifting task reassigned and additional rest arrangements agreed with the worker. Supervisor to review how the changes are working at the recorded review point.
Fictional example of record wording. Use the actual evidence and approved arrangements for your job; this is not a completed report or an instruction to carry out the work.
See it filled in
A completed pregnancy workplace risk assessment report, made by SiteSurvey from a fictional site visit: every answer, the photos, the guidance that applied and the sign-off, ready to send as a PDF.
Pregnancy Workplace Risk Assessment FAQs
How should I record “Agreed changes to conditions or hours”?
Record agreed changes to work and when their effectiveness will be reviewed. Keep unnecessary medical details out of the assessment.
Should medical records be attached?
No medical upload is requested. Record the relevant work adjustment and a secure reference to advice only where needed.
Is one assessment enough for the whole pregnancy?
No. Review it as pregnancy progresses or work changes, and record an agreed review date.
Does signing establish fitness for work?
No. The signature records the information entered. Clinical advice and the employer’s duties remain separate.
What are the limits of this template?
This records workplace controls, not a medical assessment. Record only necessary work restrictions and references, avoid clinical histories, and restrict access to personal information.
Can I complete this form on site and share the record?
In the SiteSurvey app the form works offline, with signatures recorded against the questions. Share the completed record as a PDF or a link. Dates and action owners are recorded fields; this form does not send reminders or update other systems.
Related
Related templates
Templates that go with the pregnancy workplace risk assessment form
A workstation assessment with equipment, posture and work-pattern checks, user concerns, assessor review, adjustments and follow-up evidence.
A young worker assessment recording tasks, experience, supervision, training, task restrictions, communication and review before and during placement.
A work-related stress assessment with team consultation, six work-design areas, evidence, organisational controls and a documented review of actions.
Hazards, who might be harmed, controls and risk scores, with a briefing record and review date.
Use this pregnancy workplace risk assessment form with your team
Add it from the form library in one click, change any question, and every completed form becomes a branded PDF report.
Start your trial →