Title Page

  • Conducted on

  • Prepared by

  • Employee name

  • Shift

  • Days into employees rotation

  • Department

  • Crew


  • Number of Re-assessments for this employee for this shift

  • If this is the second event click "yes" below, contact HR, skip the rest of this form and fill out the travel home form.

  • How do you feel?

  • What did you do to revive yourself during your rest time?

  • Did the additional break benefit you?

  • Do you feel that you are ready to return to duty?

  • Employee Signature:

  • Supervisor Signature:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.