Free Occupational Health Assessment Template
Occupational Health Assessment
This Occupational Health Assessment form is designed to evaluate an employee's fitness for work, identify potential health risks, and recommend necessary workplace adjustments. Use the form to document findings, assess risks, and guide appropriate interventions.
I. Employee Information
Name
Date of Birth
Job Title
Department
Assessment Date
II. Purpose of Assessment
Reason for Assessment
Specific Concerns
III. Job Description
Key Responsibilities
Work Environment
IV. Medical History
Past Medical History
Current Medications
Allergies
V. Physical Examination
Vital Signs
|
Parameter |
Measurement |
Normal Range |
|---|---|---|
|
Blood Pressure |
125/82 mmHg |
90/60 - 120/80 mmHg |
Musculoskeletal Examination
Other Relevant Examinations
VI. Assessment of Fitness for Work
Fitness Level
-
Fit for Work Without Restrictions:
-
Fit for Work With Restrictions
-
Temporarily Unfit for Work
-
Unfit for Work
Workplace Modifications Required
VII. Risk Assessment
Potential Work-Related Health Risks
|
Risk |
Description |
Risk Level |
Control Measures |
|---|---|---|---|
|
Back Injury Exacerbation |
Risk of re-injury during manual handling |
High |
Limit lifting, provide ergonomic tools |
