Medical Deficiency Assessment SENTINEL MEDICAL DEFICIENCY RISK ASSESSMENT / ASSESSMENT Name of person being assessed * Name of person being assessed First First Last Last Date of assessment * Medical Deficiency * Scope of work undertaken * Assessment of Risk & Control Measures Are there any tasks that we carryout that will have an effect of the individuals ability to undertake our scope of activities? * YESNO Control Measures * Would the deficiency cause additianal hazards to the worksite? * YESNO Control Measures * Would The Deficiency cause additional hazards to the pedestrians? * YESNO Control Measures * Would The Deficiency cause additional hazards to work colleagues? * YESNO Control Measures * Would The Deficiency cause additional hazards when operating plant? * YESNO Control Measures * Would The Deficiency cause additional hazards when operating small tools? * YESNO Control Measures * Would The Deficiency cause additional hazards when driving? * YESNO Control Measures * Is the individual safe to undertake scope of the business ativities? * YESNO Control Measures * Is the individual aware that they need to raise concerns where they feel the deficiency held may effect safe working? * YESNO Control Measures * Additional Information Name of person undertaking the assessment * Name of person undertaking the assessment First First Last Last Signature * Clear If you are human, leave this field blank. Submit
