Epilepsy risk assessment template – employee

Name

Job title          

Assessment

Date of assessment   

Symptoms and triggering factors

YES/NO

What can I do to avoid these symptoms?

Which accommodations could I ask my employer for?

Which actions should I take if I am exposed to the factor?

Done

Light (photosensitivity)

 

 

 

 Covering one eye/Blue lenses

 

Photosensitivity to patterns

 

 

 

 Covering one eye/ Blue lenses

 

Reflex epilepsy (Sounds)

 

 

 

Avoiding specific sounds

 

Reflex epilepsy (Reading)

 

 

 

 

 

Reflex epilepsy (Startle)

 

 

 

 

 

Symptoms and triggering factors

YES/NO

What can I do to avoid these symptoms?

Which accommodations could I ask my employer for?

Which actions should I take if I am exposed to the factor?

Done

Tonic-clonic Seizures

 

 

 

 

 

Tonic Seizures

 

 

 

 

 

Myoclonic Seizures

 

 

 

 

 

Absence seizures

 

 

 

 

 

Falls

 

 

 

 

 

Focal seizures with awareness impairment

 

 

 

 

 

Focal seizures without awareness impairment

 

 

 

 

 

Atonic seizures

 

 

 

 

 

Head drop

 

 

 

 

 

 

Myoclonic movements

 

 

 

 

 

Lack of concentration

 

 

 

 

 

Balance problems

 

 

 

 

 

Stress

 

 

 

 

 

Fatigue

 

 

 

 

 

Other

 

 

 

 

 

This template based on the Epilepsy Action Employer toolkit. See employers.epilepsy.org.uk for more resources to help support people with epilepsy at work.