Fatigue Management- Extended working hours approval form

• Conducted on

  Date

• Prepared by

• Shift

  Days

  Nights

• Day in rotation

  Select 1 2 3 4 5 6 7 8

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

• Crew

  Select Crew 1 Crew 2 Crew 3 Crew 4 Straight Days Other

  • Crew 1
  • Crew 2
  • Crew 3
  • Crew 4
  • Straight Days
  • Other

• Department

  Select Ore process Mine Admin/Tech service Mill Fixed Maint Mobile Maint Contractor

  • Ore process
  • Mine
  • Admin/Tech service
  • Mill
  • Fixed Maint
  • Mobile Maint
  • Contractor

• Employee Name

• Reason for working in excess of 14 hours

  Select Production loss Critical Job Critical employee to job Environmental Safety Incident Other (please add note)

  • 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

  Yes

  No

• Briefly explain:

• Briefly explain:

Fatigue risk assessment

• Work Schedule

  Scheduled shift

  Call out/Extra shift

  Extended shift

• How many hours have been worked already?

  Select 1-5 6-10 11+ This is filled out after the shift

  • 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?

  Yes

  No

• Has the employee taken a break during this shift?

  Yes

  No

• Has the employee taken lunch during this shift?

  Yes

  No

• Does the employee believe they are fit for this work?

  Yes

  No

• Physical signs of fatigue (mark all that apply)

  Select Yawning Heavy eyelids eye rubbing head drooping None noted

  • Yawning
  • Heavy eyelids
  • eye rubbing
  • head drooping
  • None noted

• Emotional signs of fatigue (mark all that apply)

  Select More quiet than usual Mood changes, decrease in tolerance Lacking energy Emotional outburst, aggression, rage None noted

  • 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)

  Select 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

  • 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

  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

  2-6

  7-11

  12-16

Fatigue score and Actions

• Fatigue risk classification

  Low risk (75% or higher)

  Mid risk (65-74%)

  High risk ( 64% or below)

• Fatigue action

  Select 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)

  • 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)

• Review with employee 10 hour off site standard, consider commute as well.

• Review with employee 10 hour off site standard, consider commute as well.

Approvals

• Supervisor conducting assessment

  Sign

• Department head or representative approving employee for extended work

  Sign