Occupational Health Assessment

Purpose: This document serves as an evaluation form for employers and occupational health professionals to assess an individual’s fitness to perform work-related duties. It supports monitoring of health status and identifying any workplace adaptations or restrictions needed for safe employment.

Employee Information

Name: {name}

Date of Birth: {dateOfBirth}

Job Title: {jobTitle}

Department: {department}

Assessment Date: {assessmentDate}

Assessment Type

{assessmentType}

Medical History Summary

{medicalHistory}

Physical Examination Findings

Mental Health and Cognitive Function

{mentalAssessment}

Workplace Risk Factors

{#riskFactors}

• {riskDescription}

{/riskFactors}

Accommodation and Restrictions

{#hasAccommodation}

• {accommodation}

{/hasAccommodation}

{^hasAccommodation}No accommodations or restrictions required at this time.{/hasAccommodation}

Assessment Conclusion

Fit for Work: {fitForWork}

Comments: {assessmentConclusion}

Assessor Information

Assessor Name: {assessorName}

Qualification: {assessorQualification}

Signature: {assessorSignature}

Date: {signatureDate}