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COVID-19 RISK ASSESSMENT FORM
The purpose of this form is to assist an employee and their manager to collectively assess the risk of exposure to the COVID-19 virus and discuss any support and adjustments that might be required to manage the risk. The Employee and Line Manager should review the employee’s Self Declaration score and if acceptable jointly complete the Risk Assessment Form.
Please take some time to read the form. Once completed, please return to [email protected]. For further guidance related to the completion of this document, please refer to the Guidance at the end of this form, and the Flow Chart supplementing this form.
Clinical academic staff should complete the Trust form only , meeting all Trust requirements and instructions. A copy of the form should be sent to [email protected] for record keeping.
SECTION 1: STAFF MEMBER DETAILS – TO BE COMPLETED BY THE EMPLOYEE
1.0 Do you consent for your data to be recorded in accordance to the above statement? Yes No
(If no, please note a referral will be made to the Occupational Health Team; please see Section 6 of this form for further details)
First name
Last name
DOB or Staff ID number
Job Title
Institute/Department
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Data Protection information: All information provided within this document will remain confidential and secure in line with GDPR and the Data Protection Act 2018). This information will be visible by your line manager, Occupational Health and Human Resources. If reasonable adjustments need to be made, there is a possibility that top line information (such as the need for additional PPE) will be made available only to parties with a ‘need to know basis’ to better support you at work. If there is an identified risk to either yourself or someone else, we have a duty of care to disclose this information to the relevant authorities. Whilst every attempt will be made to include you in this decision, this may not always be possible.
Strictly confidential
Name of manager
Your contact number
Your email address
Date of self-declaration
Signature
Please also refer to the University webpages https://www.sgul.ac.uk/news/alerts/return-to-site to assist your risk assessment. The information will be regularly updated.
1.1. Have you received a ‘shielding letter’ from the NHS Coronavirus Service or your GP or Specialist Unit informing you that you are ‘clinically extremely vulnerable’? Yes No
If yes, please skip to Section 6 of the form, as a referral will need to be made to Occupational Health. Please follow the recommended advice as listed on the letter and you should continue shielding at home until told otherwise.
If you have a medical condition outlined below but have not received a shielding letter, an urgent referral will need to be made to Occupational Health, see Section 6.
If no, please continue to Section 2.
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THE CONDITIONS RECOMMENDED FOR SHIELDING BY GOVERNMENT GUIDANCE:
1. Solid organ transplant recipients
2. People with specific cancers:
a. People with cancer who are undergoing active chemotherapyb. People with lung cancer who are undergoing active radical radiotherapyc. People with cancers of the blood or bone marrow such as leukaemia,
lymphoma or myeloma who are at any stage of treatment
d. People having immunotherapy or other continuing antibody treatments for cancer
e. People having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
f. People who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
3. People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary disease (COPD)
4. People with rare diseases that significantly increase the risk of infections (such as SCID, homozygous sickle cell)
5. People on immunosuppression therapies sufficient to significantly increase risk of infection
6. Women who are pregnant with significant heart disease, congenital or acquired
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SECTION 2: SELF DECLARATION OF RISK FACTORS – TO BE COMPLETED BY EMPLOYEE
Please mark the below questionnaire to the best of your knowledge. You can choose to give the total score only if you do not wish to disclose individual conditions. Your manager may refer to Occupational Health for verification of the score.
Risk Factor Risk score Score2.1 Age group
16 – 49 0.050 – 59 1.060 – 69 2.0
70 and above 4.0
2.2 Gender assigned at birthMale 1.0
Female 0.5
2.3 Health condition (comorbidity)Heart disease (i.e. hypertension on treatment, past heart attack, angina, heart failure, heart arrhythmia on treatment, heart surgery, valve disease)
1.5
Diabetes mellitus on treatment (insulin or tablets) 1.5Chronic lung disease: Asthma on regular steroid inhaler, recent short courses of steroid
tablets, Immunosuppressive drugs, current symptoms or past hospital admission.
COPD, fibrosing lung disease, bronchiectasis and cystic fibrosis etc. who were advised by GP or specialist that shielding not required
1.5
Chronic kidney disease needing Hospital clinic monitoring 1.5Chronic Liver disease with liver fibrosis or active hepatitis 1.0Chronic Rheumatic conditions such as Rheumatoid arthritis, SLE etc. 1.0Immunosuppressive therapy, conditions causing immune deficiency and HIV/AIDS - steroid and other immunosuppressive medication, except steroid inhalers and short courses of steroid tablets for asthma.Check the advice given by the GP or specialist clinic on the risk to COVID
2.0
Recent history of cancer (within 1 year but not covered by shielding as in section 1.2) or past history of Lymphoma or Leukaemia in remission
2.0
Chronic neurological conditions including Cerebral Palsy and Learning Difficulties (i.e. Muscular dystrophy, Myasthenia, other neurological muscle disorders, Parkinson disease, MND, MS, nerve damage affecting swallowing /breathing)
2.0
Sickle Cell disease, Thalassaemia or blood disorders under specialist clinic – Staff to check with specialist on need for ‘shielding’– section 1.2
1.5
Obesity : use the BMI calculator tool belowhttps://www.nhs.uk/live-well/healthy-weight/bmi-calculator/
– BMI more than 30- 39: 1.0
BMI 40 or more 2.0
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2.4 Other risk factorsBelong to a Black, Asian or other minority ethnic (BAME) group (please
see section 2.4 of the guidance documentation for further information)1.0
Risk scores based on publications listed in Section 7 of Guidance Notes. Please note that the above scoring criteria may not always accurately reflect the level of risk in every case and may therefore not provide an accurate risk score. If required, a further discussion or referral to Occupational Health to thoroughly assess the impact of risk can be conducted. Please visit Section 6 to complete an Occupational Health Referral.
Total Score
2.5 Are you pregnant? Yes No (If yes, the separate Risk assessment: new and expectant mothers form (Word), found at https://www.sgul.ac.uk/about/governance/policies/staff-only-policies/new-and-expectant-mothers-in-the-workplace should be conducted in addition to this document).
2.6 Caring responsibilities and Travel to work
If you have any issues regarding caring responsibilities and/or travel to work, please discuss with your line manager.
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SECTION 3: MANAGER’S DOCUMENTATION OF RISK ASSESSMENT FOR COVID-19 – TO BE COMPLETED BY MANAGER
CLASSIFICATION OF RISKS AND IDENTIFICATION OF HIGH-RISK TASKS
3.1. Classification of risk of the staff member (Please view Section 3.1 of the guidance
documentation for further information)
Low risk (0 – 3.9)
High risk (4 – 6.9)
Very high risk (7 and above)
3.2. Whilst in work, is the member of staff in a patient/public facing area?
Yes – see 3.2.1
No
3.2.1 If No, can you avoid using common areas shared with the Trust?
Yes
No3.2.2 Is your working area Covid secure?
(more information is available here)YesNo
3.3. Identify and put a tick in any of the essential work tasks with excess risk to COVID that the staff member CANNOT undertake as part of their job even with PPE and adjustments:
Consider: Risk category of staff – see 3.1 Whether staff member is in a
patient/public facing area – see 3.2 Risk level of area – see 3.3 Difficulty in controlling the risk even with
sufficient PPE and social distancing because of the inherent nature of work
Environmental issues, e.g. office space, shared equipment etc.
Administrative roles where social distancing is not possible, and adjustments such as barrier shields or limiting number of people entering at a time is not possible
Face to face communication with patients/public
Therapeutic contact (e.g. physiotherapy, psychological therapy, pharmacy, occupational therapy)
Clinical observations/assessment
Clinical examination/procedures
Aerosol generating procedures
Other – please specify:
Additional notes:
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SECTION 4: CONTROL MEASURES TO MANAGE THE RISKS OF COVID-19
Please note that over time these answers may change. It is both the manager and employee’s responsibility to ensure that the information below is kept up to date.
Complete all 4.1. Up to date with Personal Safety and social distancing procedures that is specific
to the role and area at present including training that is applicable to controlling COVID-19 exposure
4.2. Aware of the PPE protocol for the area and role
4.3. Aware of government social distancing guidelines
4.4. Aware of government hand-hygiene guidelines
4.5. Aware of face-covering guidelines.
SECTION 5: OUTCOME OF MANAGER’S RISK ASSESSMENT
5.1 Choose ONE of the options below and give further information as required in box 5.2:
/
Continue in same area and role
Continue in same area but restricted from certain tasks:Please clearly outline the tasks restricted and adjustments agreed below
Redeployed to less risk area – (seek advice from HR if required) Outline the area redeployed to and the reasons below
Combination of remote working and non-patient/public facing work:Outline the agreed arrangements below (seek advice from HR if required)
Remote working including home working:Outline the agreements below (seek advice from HR if required)
Any other outcome other than the above (please provide details):
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GUIDE FOR INTERPRETATION OF SCORES ACHIEVED IN SECTION 2 – see guidance notes for details 0 – 3.9 Indicates a Low Risk
Continue current duties with adherence to Personal Safety and Social Distancing Guidance 4-6.9 Indicates a High Risk
Review social distancing taking into account Covid-secure arrangements in workplace, as well as PPE use where appropriate. Discuss modification or restriction from duties, if required (i.e. where social distancing is not possible). In most cases it would be anticipated that social distancing and Covid-secure arrangements would be sufficient to mitigate most risks. However, if the risk remained high after considering these adjustments, redeploy to low risk areas and/or implement partial or full remote working to control the risk.
Greater than 7 Indicates a Very High RiskWork from home.
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5.2 Give further information if required here:
5.3 Please state your review plan (Recommended that you regularly review, if possible once a month, or as soon as there is any change to employee’s health or there is a change in the risk level to COVID as determined by government /the University:
Managers, irrespective of Occupational Health referral, please send a copy of this completed risk assessment to [email protected] to be kept on the employee’s personnel file. If this is being completed electronically, please attach an e-signature, or if this is not possible, please add initials and copy in the employee to the email sent to hr [email protected]
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SECTION 6: OCCUPATIONAL HEALTH REFERRAL
Managers, please contact HR if a referral to Occupational Health is required.
A constructive discussion with a manager and employee is the best way to achieve a good outcome in terms of risk reduction, achieving innovative risk management by adjustments and support whilst maintaining essential service provision. A referral should not be a substitute for a good constructive engagement between managers and employees. A referral should be made when one or more of the following criteria is met:
a) The employee did not wish to discuss confidential medical information that is in Section 2 or not covered in Section 2 but is of substantial nature that will affect risk of COVID-19 infection; or
b) Prefers to not disclose this information to their line manager or to maintain confidentiality; or c) Can confirm they have been classed as ‘clinically extremely vulnerable’ and have been advised
by their medical practitioner that they should be shielding or in ‘very high risk’ category; ord) Employee or manager or both feel that the risk assessment needs further discussion with
Occupational Health Practitioner to establish the risk and adjustments as there is concern that the risk score did not reflect the risk accurately.
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ACCOMPANYING GUIDANCE DOCUMENTATION FOR COVID-19 RISK ASSESSMENT FORM
This guidance documentation has been written to support managers through the process of completing the Covid-19 risk assessment form to support all staff.
PURPOSE OF FORM
To assess the risk of exposure to the COVID-19 virus To provide an opportunity for the employee and line manager to discuss the support and
adjustments to control the risk To create a space for an open dialogue to occur between the line manager and employee
For ease of use, the number system used on the left hand side of this documentation corresponds to the question in the original form. Because of this, some points may be missing as no additional guidance for the point is required.
SECTION 1: STAFF MEMBER DETAILS
Question Guidance1.1 This section requests the staff member to fill out their details and consent to
Occupational Health, Human Resources and their line manager to sharing the information.
If you have any general queries in relation to completing this form, please email [email protected]
All information received within this documentation MUST NOT be discussed or shared with any other party under any circumstances, unless consent has been provided and recorded or it is on a ‘need to know’ basis. Once completed, the document must be sent via a SGUL email address immediately to [email protected] copying in the individual to whom the form relates. This email will act as an e-signature confirming both parties agree.
If the member of staff refuses their consent in completing this form, please contact HR so that a referral can be made to the Occupational Health Team.
It is permitted for an employee to give a calculated score without disclosing their detailed health information. If this is the case, please make a note of the recorded score. This can be verified with the Occupational Health department if required.
1.2 If the employee is in receipt of a ‘shielding letter’ from the NHS Coronavirus Service or their GP or Specialist Unit, the employee should continue to follow government advice and shield at home until further information is provided. There is no need to complete the rest of the form, however the form must be submitted and a referral to Occupational Health must be made so that a record of this outcome can be noted.
The system used to identify those who need ‘shielding’ may not have captured all individuals who are at risk of serious COVID illness. If there are employees who have not received such a letter but have a condition identified below, they should be referred urgently for an assessment by the Occupational Health department.
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They should not have contact with patients/public who are known or suspected to have COVID infection whilst the assessment is taking place.
Health conditions that require maximum protection: staff would have already received a ‘shielding letter’ from NHS Coronavirus Service, their GP or their Specialist Unit
1. Solid organ transplant recipients
2. People with specific cancers: People with cancer who are undergoing active chemotherapy People with lung cancer who are undergoing active radical radiotherapy People with cancers of the blood or bone marrow such as leukaemia,
lymphoma or myeloma who are at any stage of treatment People having immunotherapy or other continuing antibody treatments
for cancer People having other targeted cancer treatments which can affect the
immune system, such as protein kinase inhibitors or PARP inhibitors People who have had bone marrow or stem cell transplants in the last 6
months, or who are still taking immunosuppression drugs
3. People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary disease (COPD)
4. People with rare diseases that significantly increase the risk of infections (such as SCID, homozygous sickle cell)
5. People on immunosuppression therapies sufficient to significantly increase risk of infection
6. Women who are pregnant with significant heart disease, congenital or acquired
SECTION 2: SELF DECLARATION OF RISK FACTORS
Question Guidance2.0 It is permitted for an employee to give a calculated score without disclosing their
detailed health information. If this is the case, please make a note of the recorded score. This can be verified with the Occupational Health department if required.
2.3 If an employee has a condition listed in this section that needs further discussion, or has a condition that is not covered within this section but is one of the below, request a referral to the Occupational Health department via HR.
Some of the outlined conditions could be of varying severity and the scoring methodology may not always be an accurate reflection of individual circumstances. If for any reason you are unsure whether this is the case, please make a referral to the Occupational Health department so that they can conduct a more in-depth risk assessment for the member of staff in question.
Medical conditions and other risk factors that increases vulnerability for serious
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COVID-19 illness and adjustments to control identified risks at work:
1. Those aged 70 or over (regardless of medical conditions)
2. Those who are pregnant
3. Underlying health condition as listed below Anyone instructed to get a flu jab as an adult each year on medical
grounds Chronic respiratory disease such as asthma, chronic obstructive pulmonary
disease (COPD), emphysema or bronchitis Chronic heart disease such as heart failure Chronic kidney disease Chronic liver disease such as hepatitis on treatment Chronic neurological conditions such as Parkinson’s disease, Motor
Neurone Disease, Multiple Sclerosis, a learning disability or cerebral palsy Diabetes Previous removal of spleen Sickle cell disease Immunosuppression as a result of conditions such as HIV and AIDS, or
medication such as steroid therapy or chemotherapy Being seriously overweight – BMI >40
2.4 For the purposes of this document, the available evidence states that BAME groups from a primarily Black and Asian background are considered to be more at risk than other ethnic minority groups. Please see https://www.bhf.org.uk/informationsupport/heart-matters-magazine/news/behind-the-headlines/coronavirus/coronavirus-and-bame-patients and Disparities in the risk and outcomes of COVID-19 (public Health England for further information.
2.5 If an employee discloses they are pregnant, a further risk assessment should be carried out in addition to this form. The separate Risk assessment: new and expectant mothers form (Word), found at https://www.sgul.ac.uk/about/governance/policies/staff-only-policies/new-and-expectant-mothers-in-the-workplace should be completed in addition to this document.
SECTION 3: CLASSIFICATION OF RISKS AND IDENTIFICATION OF HIGH RISK TASKS
3.1 0 – 3.9 Indicates a Low RiskContinue current duties with adherence to Personal Safety and Social Distancing Guidance
4-6.9 Indicates a High RiskReview social distancing taking into account Covid-secure arrangements in workplace, as well as PPE use where appropriate. Discuss modification or restriction from duties, if required (i.e. where social distancing is not possible). In most cases it would be anticipated that social distancing and Covid-secure arrangements would be sufficient to mitigate most risks. However, if the risk
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remained high after considering these adjustments, redeploy to low risk areas and/or implement partial or full remote working to control the risk.
Greater than 7 Indicates a Very High RiskWork from home.
3.2 If the member of staff is in a patient/public facing area, further consideration should be made in conjunction with the answers provided to help you to decide an overall risk score for the employee.
A Covid-secure area is an area in which:
A COVID-19 risk assessment has been carried out and shared with the people who work in the area
There is easy access to handwashing/hand sanitising facilities The area is cleaned regularly Social distancing can be maintained at all times with staff 2m apart
SECTION 4: CONTROL MEASURES TO MANAGE THE RISKS OF COVID-19 FOR ALL STAFF
4.3-4.5 Further information on government social distancing, hand hygiene and face-covering guidelines can be found at https://www.gov.uk/coronavirus
SECTION 5: OUTCOME OF MANAGER’S RISK ASSESSMENT
5.0 Completing this form should assist in making an informed decision to mitigate the risks of contracting Covid-19. If you are unsure on anything, it is recommended you refer the employee to Occupational Health.
It is recommended that you regularly review this risk plan with the employee. It is also important that you inform the employee to request a review if their healthcare requirements change over this period.
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SECTION 6: SUPPLEMENTARY GUIDANCE DOCUMENTATION
You may find that completing this form may raise additional questions. To support you in finding the right information, the following documentation may be useful for you to consider:
Description Where it is foundGuidance and forms for returning to work after coronavirus lockdown
The safety and wellbeing of students, staff and our wider community are our top priority. We continue to monitor Government and Public Health England advice and the guidance on this page will be updated to reflect any Coronavirus specific developments.
https://www.sgul.ac.uk/about/our-professional-services/safety-health-and-environment/guidance-and-forms-for-returning-to-work-after-coronavirus-lockdown
Personal Safety and Social Distancing Guidance
St George's response to the novel coronavirus for all staff and students returning to the site.
https://www.sgul.ac.uk/news/alerts/return-to-site/personal-safety-and-social-distancing-guidance
Health and Wellbeing
Mental HealthOccupational health
https://www.sgul.ac.uk/for-students/student-support/health-and-wellbeing/mental-health
Counselling Service It is available to all undergraduates and postgraduates studying at St George’s. The service is also available to university staff. It is free and confidential.
https://www.sgul.ac.uk/for-students/student-support/health-and-wellbeing/mental-health/counselling-service
How do I make an appointment with the Counselling service?
1. Via the online booking chart.2. By phone 020 8725 3628 (internal
3628)3. By emailing [email protected]
Employee assistance programme (EAP) provided by Confidential Care
Employee assistance programme (EAP) for staff Free service.
The Confidential Care Employee Assistance Programme have adapted their service in the event of Coronavirus. They will be continuing to provide their telephone service during their time. To access the service, please follow these instructions.
Able to advise on debt and financial management, legal and tax issues and family care, as well as offering counselling and emotional support.
Download the EAP leaflet (PDF) for more information.
well-online.co.uk
username: sglogin
password: wellbeing
Email: [email protected]
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Pregnancy Risk Assessment
The Risk Assessment Form for Pregnant Staff is to be completed by the line manager. Risk assessment: new and expectant mothers form (Word), found at https://www.sgul.ac.uk/about/governance/policies/staff-only-policies/new-and-expectant-mothers-in-the-workplace should be conducted in addition to this document.
Available at:https://www.sgul.ac.uk/about/governance/policies/staff-only-policies/new-and-expectant-mothers-in-the-workplace should be conducted in addition to this document.
Safety, Health, Environment and Wellbeing
https://www.sgul.ac.uk/about/our-professional-services/safety-health-and-environment
Absence, Leave and Sickness
links to the various types of leave available at SGUL and the procedure for sickness absence management.
Family leave, Special leave
https://www.sgul.ac.uk/about/our-professional-services/human-resources/absence-leave-and-sickness
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SECTION 7: REFERENCES CONSIDERED FOR SCORING RISK FACTORS
The risk scores in Section 2 of the Risk Assessment Form was based on the information in the publications referenced below, as well as other resources such as publications from Society of Occupational Medicine, Faculty of Occupational Medicine, British Society of Gastroenterologists and British Society of Rheumatology. The Occupational Health physicians also discussed the practice across the NHS in relation to managing risks of COVID infection among healthcare workers to estimate a score.
1. Association of Local Authority Medical Advisors (ALAMA). COVID-19 Medical Risk Management. https://alama.org.uk/covid-19-medical-risk-management/
2. Banerjee A et al. Estimating excess 1- year mortality from COVID-19 according to underlying conditions and age in England: a rapid analysis using NHS health records in 3.8 million adults. Pre-print available from: https://www.medrxiv.org/content/10.1101/2020.03.22.20040287v1.full.pdf
3. Docherty AB et al. Features of 16,749 hospitalised UK patients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol. Pre-print available from: https://www.medrxiv.org/content/10.1101/2020.04.23.20076042v1.full.pdf
4. Huang I et al. Diabetes mellitus is associated with increased mortality and severity of disease in COVID-19 pneumonia – A systematic review, meta-analysis, and meta-regression. Diabetes Metab Syndr. 2020 Apr 17;14(4):395-403. doi: 10.1016/j.dsx.2020.04.018. Available from: https://www.sciencedirect.com/science/article/pii/S1871402120300837?via%3Dihub
5. Khunti K et al. Risk reduction for NHS staff at risk of COVID-19 infection – Faculty of Occupational Medicine working group. https://www.fom.ac.uk/wp-content/uploads/Risk-Reduction-Framework-for-NHS-staff-at-risk-of-COVID-19-infection-12-05-20.pdf
6. Mehra M et al. Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19. N Engl J Med. 2020 May 1. Available from: https://www.nejm.org/doi/full/10.1056/NEJMoa2007621 (This article was retracted on Jun 4, 2020 DOI: 10.1056/NEJMc2021225 and the evidence will be reviewed.)
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