Fillable Printable Sample Health and Safety Risk Assessment
Fillable Printable Sample Health and Safety Risk Assessment
Sample Health and Safety Risk Assessment
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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)
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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
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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
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