Fatigue Management- Assessment and event form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Employee name:

• Department

  Select Maintenance Mine Ore process Ancillary Mill Tech Services Safety bonus contributions Dewatering Security

  • Maintenance
  • Mine
  • Ore process
  • Ancillary
  • Mill
  • Tech Services
  • Safety bonus contributions
  • Dewatering
  • Security

• Which Maint group

  Select Fixed Electrical Mobile

  • Fixed
  • Electrical
  • Mobile

• Which group

  Select Met lab Pads Plants Refinery

  • Met lab
  • Pads
  • Plants
  • Refinery

• Which group

  Select General store Golf course Day care Hadley Maintenance Warehouse/Purchasing Clinic

  • General store
  • Golf course
  • Day care
  • Hadley Maintenance
  • Warehouse/Purchasing
  • Clinic

• Which group

  Select Accounting HR CI Management Safety

  • Accounting
  • HR
  • CI
  • Management
  • Safety

• Which group

  Select Environmental Assay lab Projects Survey Sampling Geotech Hydrology Geology

  • Environmental
  • Assay lab
  • Projects
  • Survey
  • Sampling
  • Geotech
  • Hydrology
  • Geology

• Which mine group

  Operation

  IT

  Drilling/Blasting

• Is the employee operating Equipment

  Yes

  No

• Equipment number(s)

• Task or Job being preformed

• Shift start time

  Date

• Shift

  Days

  Nights

• How many days into rotation

  Select 1 2 3 4 5 6 7 8

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8

• Did you travel 100 miles or more to get to work in the last 24 hours?

  Yes

  No

• Crew

  Select Crew 1 Crew 2 Crew 3 Crew 4 Crew A Crew B Straight days Other

  • Crew 1
  • Crew 2
  • Crew 3
  • Crew 4
  • Crew A
  • Crew B
  • Straight days
  • Other

• Time the audit/event occurred

  Beginning of shift

  Middle of shift

  End of shift

• What is your average daily commute

  20 miles or less

  20-50 miles

  greater than 50 miles

Select observation type

• What is the reason you are doing a fatigue assessment

  DSS event

  Fatigue risk assessment

  Observed behavior

  Alert meter 2nd variation

• What behavior

  Asleep

  Erratic behavior

  Other (please add note)

• Does the employee believe this event could be due to a medical condition? If so, please stop the assessment and contact the on call HR person

  Yes

  No

Fatigue root cause

• Can the employee explain why they are fatigued

  Select Stress Lack of sleep Use of medicine Grief/Sadness Sedentary job/task Other (please comment)

  • Stress
  • Lack of sleep
  • Use of medicine
  • Grief/Sadness
  • Sedentary job/task
  • Other (please comment)

Review of DSS Video

• Location of event

  Select Gold Hill Pit Gold Hill Waste Dump Gold Hill Dpad North Ramp Fuel Skid Ramp Waste Dump Ramp Dpad Ramp Southern RM Haul Roads Northern RM Haul Roads Tdam Cell B

  • Gold Hill Pit
  • Gold Hill Waste Dump
  • Gold Hill Dpad
  • North Ramp
  • Fuel Skid Ramp
  • Waste Dump Ramp
  • Dpad Ramp
  • Southern RM Haul Roads
  • Northern RM Haul Roads
  • Tdam Cell B

• Physical

  Select Eyes closed mouth open head back or to the side other None observed

  • Eyes closed
  • mouth open
  • head back or to the side
  • other
  • None observed

• Does the employee believe this event could be due to a medical condition? If so, please stop the assessment and contact the on call HR person

  Yes

  No

Fatigue root cause

• Can the employee explain why they are fatigued

  Select Stress Lack of sleep Use of medicine Grief/Sadness Sedentary job/task Other (please comment)

  • Stress
  • Lack of sleep
  • Use of medicine
  • Grief/Sadness
  • Sedentary job/task
  • Other (please comment)

• Has the alert meter (game) results been reviewed with the employee

  Yes

  No

• Does the Employee believe this event could be due to a medical condition?

  Yes

  No

• Please stop the assessment and contact the on call HR person

• Is there reason to suspect substance abuse?

  Yes

  No

• Contact the On call safety person to conduct a test

Reasonable Suspicion form

• A supervisor must have a reasonable suspicion that an employee is under the influence of, or impaired by alcohol, a controlled substance, or other drugs in order to request testing. (Check all that apply)

• Walking

  Select Staggering Falling Unsteady Holding on Normal

  • Staggering
  • Falling
  • Unsteady
  • Holding on
  • Normal

• Standing

  Select Swaying Rigid Unable to stand Normal

  • Swaying
  • Rigid
  • Unable to stand
  • Normal

• Speech

  Select Shouting Slow Rambling Mute Slurred Incoherent Normal

  • Shouting
  • Slow
  • Rambling
  • Mute
  • Slurred
  • Incoherent
  • Normal

• Actions

  Select Fighting Threatening Calm Drowsy Profanity Overexcited Hostile Erratic Cooperative Crying

  • Fighting
  • Threatening
  • Calm
  • Drowsy
  • Profanity
  • Overexcited
  • Hostile
  • Erratic
  • Cooperative
  • Crying

• Eyes

  Select Bloodshot Watery Dilated Glassy Droopy Closed Normal

  • Bloodshot
  • Watery
  • Dilated
  • Glassy
  • Droopy
  • Closed
  • Normal

• Face

  Select Flushed Pale Sweaty Normal

  • Flushed
  • Pale
  • Sweaty
  • Normal

• Appearance/Clothing

  Select Messy Dirty Partially dressed Neat Appropriate for working conditions

  • Messy
  • Dirty
  • Partially dressed
  • Neat
  • Appropriate for working conditions

• Breath

  Select Alcoholic Odor Faint Alcoholic odor No odor

  • Alcoholic Odor
  • Faint Alcoholic odor
  • No odor

• Visual observation of use

  Select Drinking Smoking Taking a pill Snorting/Inhaling Injecting None

  • Drinking
  • Smoking
  • Taking a pill
  • Snorting/Inhaling
  • Injecting
  • None

• Other Basis for requiring testing

• Signature of Witness

  Sign

• Signature of Supervisor

  Sign

Meter and Prism results

• What is the level of fatigue from the 2nd alert meter game

  Green

  Yellow

  Red

  Purple

• What is the level of fatigue from the Prism report for this employee for today

  Green

  Yellow

  Red

  Purple

Work Schedule

• Work Schedule

  Scheduled Shift

  Call Out/Overtime

  Extended Shift

• How many hours have been worked

  Select 0-2 3-4 5-6 7-8 9-10 11-12 Greater than 12 hours

  • 0-2
  • 3-4
  • 5-6
  • 7-8
  • 9-10
  • 11-12
  • Greater than 12 hours

• Has the employee taken a break during shift

  Yes

  No

• Has the employee taken a break during shift

  Yes

  No

• Has the employee taken a break during shift

  Yes

  No

• Has the employee taken a break during shift

  Yes

  No

• Has the employee taken a break during shift

  Yes

  No

Signs and Symptoms

• Physical

  Select Yawning Heavy eyelids Rubbing eyes head drooping None observed Other

  • Yawning
  • Heavy eyelids
  • Rubbing eyes
  • head drooping
  • None observed
  • Other

• Emotional

  Select More quiet than usual Mood changes, low tolerance or irritability Lack of energy Emotional outburst, aggression, rage None observed Other

  • More quiet than usual
  • Mood changes, low tolerance or irritability
  • Lack of energy
  • Emotional outburst, aggression, rage
  • None observed
  • Other

• Mental

  Select Difficulty concentrating on the task Difficulty remembering what you are doing Failure to communicate important information Accidentally doing the wrong thing Lapses in attention Failure to anticipate events/actions None observed Other

  • Difficulty concentrating on the task
  • Difficulty remembering what you are doing
  • Failure to communicate important information
  • Accidentally doing the wrong thing
  • Lapses in attention
  • Failure to anticipate events/actions
  • None observed
  • Other

Sleep Wake History

• How much sleep have you had in the past 24 hours

  Select 2 3 4 5 6 7 8

  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8

• How much sleep have you had in the past 48 hours

  12-16

  7-11

  2-6

Assessment and Controls

• Assessment category

  DSS/Observed

  Alert meter

• What is the Total Fatigue assessment score

• Select fatigue controls

  Select 80% or above- Remain with current duties and assignments 70-79%- Assign rotating task or provide temporary duties with supervisory checks. Optional 1 hour pit stop. Re-evaluation required if pit stop is used. 60-69%- Mandatory 1 hour pit stop. Re-evaluation required. Below 60%- Removal from all work, please fill out travel home form including travel plan.

  • 80% or above- Remain with current duties and assignments
  • 70-79%- Assign rotating task or provide temporary duties with supervisory checks. Optional 1 hour pit stop. Re-evaluation required if pit stop is used.
  • 60-69%- Mandatory 1 hour pit stop. Re-evaluation required.
  • Below 60%- Removal from all work, please fill out travel home form including travel plan.

• What is the Total Fatigue assessment score

• Select fatigue controls

  Select 80% or above- Remain with current duties and assignments, ensure hydration as part of the shift. 70-79%- Assign rotating task or provide temporary duties with supervisory checks every 6 hours. Drink 8 oz. of water every hour. 60-69%- Remove from any safety sensitive, or high risk tasks. Drink 8oz. of water every hour. A short rest may be appropriate with supervisory checks every 4 hours. Below 60%- Removal from all work, please fill out travel home form including travel plan.

  • 80% or above- Remain with current duties and assignments, ensure hydration as part of the shift.
  • 70-79%- Assign rotating task or provide temporary duties with supervisory checks every 6 hours. Drink 8 oz. of water every hour.
  • 60-69%- Remove from any safety sensitive, or high risk tasks. Drink 8oz. of water every hour. A short rest may be appropriate with supervisory checks every 4 hours.
  • Below 60%- Removal from all work, please fill out travel home form including travel plan.

• Notify HR

  Yes

• Description of the work activity being performed

• Reason for sending employee home

• Miles to employees home

• Level of fatigue risk

  Low

  Moderate

  High

• Does the employee think they can drive home

  Yes

  No

• Does the employee want to take a "pit stop" prior to driving home

  Yes

  No

• Please list any alternatives to the employee driving themselves home

• Does the employee accept the responsibility of safety traveling home

  Yes

  No

• Please list the plan for employee transport

Notifications and Signatures

• List the HR contact person approving the employee to travel home

• Inform the employee that at least a 10 hour break is required prior to returning to work
Supervisor follow ups

• Length of time in hours, between assessments

• Was the alert meter used again for this assessment

  Yes

  No

• What was the employees score

• Is the employee following the hydration guidance of 8oz. every hour

  Yes

  No

• What level of fatigue would the employee rate themselves at

  Low

  Medium

  High

  Severe

• Based on your re-assessment what actions are required

  Select Employee can return to work with no follow ups Employee can return to work with follow ups Employee cannot return to work and will need follow ups

  • Employee can return to work with no follow ups
  • Employee can return to work with follow ups
  • Employee cannot return to work and will need follow ups
Supervisor follow ups

• Length of time in hours, between assessments

• Was the alert meter used again for this assessment

  Yes

  No

• What was the employees score

• Is the employee following the hydration guidance of 8oz. every hour

  Yes

  No

• What level of fatigue would the employee rate themselves at

  Low

  Medium

  High

  Severe

• Based on your re-assessment what actions are required

  Select Employee can return to work with no follow ups Employee can return to work with follow ups Employee cannot return to work and will need follow ups

  • Employee can return to work with no follow ups
  • Employee can return to work with follow ups
  • Employee cannot return to work and will need follow ups

Completion details

• Additional Comments

  Yes

  No

• Comments/feedback

• Employee signature

  Sign