Information
Reason for working in excess of 14 hours
- Production loss
- Critical Job
- Critical employee to job
- Environmental
- Safety
- Incident
- Other (please add note)
Briefly Explain
Have you considered alternatives to working extended hours
Fatigue risk assessment
Work Schedule
How many hours have been worked already?
- 1-5
- 6-10
- 11+
- This is filled out after the shift
Do you believe the employee has the ability to think clearly and work safely for this extended shift?
Has the employee taken a break during this shift?
Has the employee taken lunch during this shift?
Does the employee believe they are fit for this work?
Physical signs of fatigue (mark all that apply)
- Yawning
- Heavy eyelids
- eye rubbing
- head drooping
- None noted
Emotional signs of fatigue (mark all that apply)
- More quiet than usual
- Mood changes, decrease in tolerance
- Lacking energy
- Emotional outburst, aggression, rage
- None noted
Mental signs of fatigue (mark all that apply)
- Difficulty concentrating on task
- Difficulty remembering what you are doing
- Lapses in attention
- Failure to communicate important information
- Accidentally doing the wrong thing
- Failure to anticipate events/actions
- None Noted
Sleep/Wake history
Sleep in the previous 24 hours
- 2
- 3
- 4
- 5
- 6
- 7
- 8
How much sleep have you had in the past 48 hours
Fatigue score and Actions
Fatigue risk classification
Fatigue action
- Low (Employee can be approved for extend work)
- Mid (Employee can be approved, but the risk of fatigue is present, other options should be considered.)
- High (Employee can not be approved for extend work)
Approvals
Supervisor conducting assessment
Department head or representative approving employee for extended work
