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Fillable Printable Sample Health and Safety Risk Assessment

Fillable Printable Sample Health and Safety Risk Assessment

Sample Health and Safety Risk Assessment

Sample Health and Safety Risk Assessment

1
Physical Activity
1.I engage in moderate physical activity outside
of work for at least 20 to 30 minutes at least 5
days of the we ek.
1 2 3 4 5
2.My physical activity includes stretching,
aerobic activity, and strength cond itioning.
1 2 3 4 5
3.I use alternative modes of transportation
whenever possible to and from various
locations (i.e. stairs instead of elevator, biking
or walking instead of driving).
1 2 3 4 5
4.I take the health benefits of physical activities
and their lasting impact seriously.
1 2 3 4 5
5.I enjoy sedentary activities rather than physical
activities.
1 2 3 4 5
Nutrition
6.I eat at least five servings of fruits and
vegetables every day (one serving equals one
half cup).
1 2 3 4 5
7.I eat at fast food restaurants less than three
times per week.
1 2 3 4 5
8.I include foods that are high in fiber in my diet
on a daily basis (i.e. whole grain breads and
cereals, beans, etc.)
1 2 3 4 5
9.I maintain a healthy weight within the
recommendations specified by a health care
professional.
1 2 3 4 5
10.I avoid eating foods that are high in fat such as
whole milk, fried foods, fatty meats, etc.
1 2 3 4 5
General Health
11.I avoid the use of tobacco products (cigarettes,
smokeless tobacco, cigars, and pipes) and limit myself
to 5 drinks of alcoho l a week. (b eer, liquor, wine)
1 2 3 4 5
12.I examine my breasts or testes on a monthly basis.
1 2 3 4 5
13.I protect my skin from sun damage by using
sunscreen, wearing hats, and/or avoiding
tanning booths and sunlamps.
1 2 3 4 5
14.I visit my dentist every six months for regular
check ups.
1 2 3 4 5
On the answer sheet provided, please circle the number w hich best identifies your response to each
corresponding statement.
1.Never or Almost Never
2.Occasionally
3.Often
4.Very Often
5.Always or Almost Always
Sample Health Risk Assessment (HRA)
2
15.I see my physician for routine check-ups,
health screenings, and disease prevention.
1 2 3 4 5
Safety
16.I wear a seat belt when traveling in a vehicle.
1 2 3 4 5
17.I stay within five miles per hour of the speed limit.
1 2 3 4 5
18.I know where to locate and properly use a first aid
kit and fire extinguisher in case of an emergency.
1 2 3 4 5
19.I use the recommended safety equipment for all
activities that I p articipate in (i.e. mouth guards,
life jackets, hard hats, etc.).
1 2 3 4 5
20.I take the proper precautions to avoid or reduce
workplace accidents. (i.e. clean up spills)
1 2 3 4 5
Social and Environmental Wellness
21.I regularly recycle my paper, plastic, glass and
aluminum.
1 2 3 4 5
22.I respect the integrity and property of my
fellow co-worker s and th e surrounding
environment.
1 2 3 4 5
23.I take time to have meaningful interactions
with family and friends.
1 2 3 4 5
24.I contribute time and/or money to at least one
organization that strives to better the
community where I live.
1 2 3 4 5
25.I regularly take interest in an d interact with
others.
1 2 3 4 5
Emotional Awareness
26.My relationships and behaviors are maintained
in a manner which is healthy for me and for
others.
1 2 3 4 5
27.I am able to develop close, personal
relationships with others.
1 2 3 4 5
28.I have positive relationships with both men and
w omen in my life.
1 2 3 4 5
29.I feel that I am a confident individual.
1 2 3 4 5
30.I am able to respect others for who they are,
regardless of race, gender, age, attitude, and
interests.
1 2 3 4 5
Mental Wellness
31.I express my feelings of anger and frustration
in ways that are not hurtful to myself or others.
1 2 3 4 5
32.I set reasonable objectives for myself and strive
to accomplish them.
1 2 3 4 5
33.I realize when I make mistakes; and I
understand the consequences that they have on
myself and others.
1 2 3 4 5
34.I feel that I have family and friends that I can
confide in to assist in managing stress.
1 2 3 4 5
3
35.I take responsibility for my actions and
understand the effects that they have on others.
1 2 3 4 5
Intellectual Wellness
36.I keep informed about social, political, and/or
current events.
1 2 3 4 5
37.I seek opportunities to learn new thing s th rough
different mediums such as television, books,
newspaper, internet, etc.
1 2 3 4 5
38.Before making decisions, I gather facts and
consider all viable options.
1 2 3 4 5
39.I enjoy activ ities such as th e arts, visiting
museu ms, or attending plays or concerts.
1 2 3 4 5
40.I enjoy learning new information on a daily
basis.
1 2 3 4 5
Occupational Wellness
41.I enjoy my work.
1 2 3 4 5
42.I am satisfied with the balance between my work time
and leisure time.
1 2 3 4 5
43.I am satisfied with my ability to manage and con trol my
work load.
1 2 3 4 5
44.The level of stress in my work environment is
manageable for me.
1 2 3 4 5
45.At work, my level of author ity is cons istent with my
level of responsibility.
1 2 3 4 5
Values, Spirituality, and Beliefs
46.I feel that my life has a purpose.
1 2 3 4 5
47. I am able to discu s s my values and beliefs with my
family and friends in a reasonable manner.
1 2 3 4 5
48. My actions are guided by my own beliefs rather than the
beliefs of ot hers.
1 2 3 4 5
49. I spend a portion of every day in personal reflection.
1 2 3 4 5
50. I am tolerant of the values and beliefs of others.
1 2 3 4 5
4
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