Fatigue Management- Travel Home Form (KINROSS)

• Conducted on

  Date

• Prepared by

• Employee name

• Job position

• Work area

• Crew

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

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

• Day into employees rotation

  Select 1 2 3 4 5 6 7 8

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

• Department

  Select Ore process Mine Admin/Tech service Mill Fixed Maint Mob Maint

  • Ore process
  • Mine
  • Admin/Tech service
  • Mill
  • Fixed Maint
  • Mob Maint

• Shift

  Days

  Nights

• Notify HR

  Yes

• Description of the work activity being performed

• Reason for sending employee home

• Miles to employees home

• Level of fatigue risk

  Low

  Moderate

  High

• Does the employee think they can drive home

  Yes

  No

• Does the employee want to take a "pit stop" prior to driving home

  Yes

  No

• Please list any alternatives to the employee driving themselves home

• Does the employee accept the responsibility of safety traveling home

  Yes

  No

• Please list the plan for employee transport

Notifications and Signatures

• List the HR contact person approving the employee to travel home

• Inform the employee that at least a 10 hour break is required prior to returning to work

• Employee signature

  Sign

• Supervisor signature

  Sign