Fatigue Management- Assessment and event form

• Conducted on

  Date

• Prepared by

• Employee name:

• Department

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

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

• Which Maint group

  Select Fixed Electrical Mobile

  • Fixed
  • Electrical
  • Mobile

• Which group

  Select Met lab Pads Plants Refinery Security

  • Met lab
  • Pads
  • Plants
  • Refinery
  • Security

• 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

• 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

  Select DSS event Incident (possibly fatigue related) Fatigue risk assessment Observed behavior

  • DSS event
  • Incident (possibly fatigue related)
  • Fatigue risk assessment
  • Observed behavior

• 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)

• 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 cause

• To the best of their ability 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)

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

• 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.

Completion details

• Additional Comments

  Yes

  No

• Comments/feedback

• Fatigue assessment completed by:

  Sign

• Acknowledgment of person assessed:

  Sign