Fatigue Management- Event Form (KINROSS)

• Conducted on

  Date

• Prepared by

• Employee name:

• Location of event

  Top to leach pad

  Top to waste haul

  Vantage to leach pad

  Vantage to waste haul

  Other

• Equipment Number

• Shift start time

  Date

• Shift

  Days

  Nights

• How many days into rotation

  Select 1 2 3 4 5 6

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6

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

  Yes

  No

• Crew

  Crew A

  Crew B

  Crew C

  Crew D

• Time the event occurred

  6:00-9:00

  9:01-12:00

  12:01-3:00

  3:01-6:00

• Yes

  No

• What is your average daily commute

  Elko- Spring Creek

  Ely

  Eureka

  Man Camp

Section 1- Work Schedule Questions

• Work Schedule

  Scheduled Shift

  Unscheduled shift

• How many hours have been worked when the event occured

  Select 1-2 3-4 5-6 7-8 9-10 11-12 Greater than 12 hours

  • 1-2
  • 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

Section 2- Supervisor Observation Questions

• Is there any reason to think the employee cannot think clearly

  Yes

  No

• Did supervisor need to review video with employee

  Yes

  No

Section 3- 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

• Wellbeing

  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

• Wellbeing

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

Section 4- 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

Section 5- Assessment and Controls

• What is the Total Fatigue assessment score

• Select fatigue controls

  Select 80% or above- Remain with current duties and assignments 79% or below- Remove from truck and Assign rotating task or provide temporary duties with supervisory checks. Optional 1 hour pit stop. Re-evaluation required.

  • 80% or above- Remain with current duties and assignments
  • 79% or below- Remove from truck and Assign rotating task or provide temporary duties with supervisory checks. Optional 1 hour pit stop. Re-evaluation required.

• Does the employee need a pit stop

  Yes

  No

Section 6- Completion details

• Fatigue assessment completed by:

  Sign

• Acknowledgment of person assessed:

  Sign