Individual Journey Management Plan

• Conducted on

  Date

• Individual Journey Management Plan

• Plan Type

  New

  Revised

  Overtime

  Contingeny

• Where is your Permanent Residence?

• Enter Permanent Address
  Address

• Is your permanent residence more than1 hour from site?

  Low: <1 hour

  Medium: 1-2 hours

  High to extremely high: >2 hours

• Do you regularly work 12 hour shifts?

  Yes

  No

• Will you exceed 16 hours of being awake while in control of a vehicle?

  Yes

  No

Employee Declaration

• By completing and submitting this form, I confirm that my commute plan will not affect my ability to meet my requirements under the Fitness for Work: Fatigue Management Plan.
  
  I also agree that all information that I have supplied on this form is correct and accurate as of the date recorded, and that I will comply with the Fitness for Work: Fatigue Management Plan. I understand that if any of these details change (or any other details that will possibly impact my ability to manage fatigue) that I am required to report this immediately to my Supervisor.

Personnel Details

• Surname

• Given Name

• Personnel Number

• Company

• Department

• Position

• Crew

  Select Dayshift A B C D Split Relief Other

  • Dayshift
  • A
  • B
  • C
  • D
  • Split
  • Relief
  • Other

• Roster Pattern

  Select Other 6D6O6N6O 1/2D6D1/2D7O7N7O 7D7O7N7O 5D2O 3D3N6O

  • Other
  • 6D6O6N6O
  • 1/2D6D1/2D7O7N7O
  • 7D7O7N7O
  • 5D2O
  • 3D3N6O

• Other (If applicable)

Emergency Contact

• Name

• Contact Number

• Relationship

Dayshift

• Daily Commute Plan

  Select 1st Dayshift Dayshifts Last Dayshift 1st Nightshift Nightshifts Last Nightshift Not Applicable

  • 1st Dayshift
  • Dayshifts
  • Last Dayshift
  • 1st Nightshift
  • Nightshifts
  • Last Nightshift
  • Not Applicable
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?

• Daily Commute Plan (Remaining shifts, If different)

• Shift

  Select 1st Dayshift Dayshifts Last Dayshift 1st Nightshift Nightshifts Last Nightshift Not Applicable

  • 1st Dayshift
  • Dayshifts
  • Last Dayshift
  • 1st Nightshift
  • Nightshifts
  • Last Nightshift
  • Not Applicable
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?

• Daily Commute Plan (Last Dayshift)

• Shift

  Select 1st Dayshift Dayshifts Last Dayshift 1st Nightshift Nightshifts Last Nightshift Not Applicable

  • 1st Dayshift
  • Dayshifts
  • Last Dayshift
  • 1st Nightshift
  • Nightshifts
  • Last Nightshift
  • Not Applicable
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?

Nightshift

• Do you undertake Nightshift?

• Nightly Commute Plan (First Nightshift)

  Select 1st Dayshift Dayshifts Last Dayshift 1st Nightshift Nightshifts Last Nightshift Not Applicable

  • 1st Dayshift
  • Dayshifts
  • Last Dayshift
  • 1st Nightshift
  • Nightshifts
  • Last Nightshift
  • Not Applicable
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?

• Nightly Commute Plan (If different)

• Shift

  Select 1st Dayshift Dayshifts Last Dayshift 1st Nightshift Nightshifts Last Nightshift Not Applicable

  • 1st Dayshift
  • Dayshifts
  • Last Dayshift
  • 1st Nightshift
  • Nightshifts
  • Last Nightshift
  • Not Applicable
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?

• Nightly Commute Plan (Last Nightshift)

• Shift

  Select 1st Dayshift Dayshifts Last Dayshift 1st Nightshift Nightshifts Last Nightshift Not Applicable

  • 1st Dayshift
  • Dayshifts
  • Last Dayshift
  • 1st Nightshift
  • Nightshifts
  • Last Nightshift
  • Not Applicable
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?
• From
  Address

• Start time

  Date
• To
  Address

• Finish time

  Date

• Activity - All

  Select Work Commute - Self Drive Commute - Company Commute - Flight Commute - Bus Rest Opportunity Sleep Opportunity Waiting Time

  • Work
  • Commute - Self Drive
  • Commute - Company
  • Commute - Flight
  • Commute - Bus
  • Rest Opportunity
  • Sleep Opportunity
  • Waiting Time

• Route distance (km)

• Additional modes of transport?

• Do you have any pre-existing medical conditions that may affect your journey management plan?

  Yes

  No

• Is your Supervisor aware of the controls for pre-existing medical condition?

  Yes

  No

• What are your additional controls measures to manage fatigue?

  Select Mandatory Sleep Periods Mandatory Rest Breaks ie Every 2 hours when driving Site Provided Travel Arrangements ie Bus, Flight Fatigue Awareness Training Supplied Accomodation ie Blackout curtains, Early Checkin/Late Checkout Other Controls

  • Mandatory Sleep Periods
  • Mandatory Rest Breaks ie Every 2 hours when driving
  • Site Provided Travel Arrangements ie Bus, Flight
  • Fatigue Awareness Training
  • Supplied Accomodation ie Blackout curtains, Early Checkin/Late Checkout
  • Other Controls

• List other controls

Traveller

• Signature - Traveller

  Sign

• I commit to abiding by the controls stated in this IJMP to adequately manage my fitness for work.

Direct Supervisor

• Signature - Direct Supervisor

  Sign

1-up Line Manager

• 1-up Line Manager

  Sign

Approved

• I have read and approve this IJMP

Not Approved

• I do not approve IJMP

• Insufficient controls

• Incorrect details

• Comments

Overall Risk Ranking

• Overall Risk Ranking

  Low Risk

  Medium Risk

  High Risk

• Date Approved

  Date

• This Individual Journey Management Plan Form shall be reviewed bi-annually or if there is a change in conditions.