Network Aviation

NAA Alertness Assessment

NAA Pilot Fatigue Survey

Use this Template

Print as PDF

Use this Template

Go digital today!

Convert your paper checklists into digital forms

Scan this QR code to use this paper checklist on your smartphone or tablet or visit https://safetyculture.com/

Information

Audit Title
Document No.
Client / Site
Conducted on
Prepared by
Location
Personnel

How much sleep have you had in he past 24 hours? (to nearest hour)
What time did you last get to sleep?
What time did you last wake up?
How would you rate the quality of sleep you had last night?
Where did you get the majority of your sleep in the past 24 hours?
- Home - own bed
- Home - other
- Mine Site accommodation
- Hotel
- Business Class Seat
- Economy Class Seat
Please rate how fatigued you currently feel.
- fully alert - wide awake
- very lively, responsive but not at peak
- okay somewhat fresh
- a little tired - less than fresh
- moderately tired - let down
- extremely tired - very difficult to concentrate
- completely exhausted - unable to function effectively
How much duty time have you had in the past 24 hours
How much flight time have you had in the past 24 hours?
Sign off

Network Aviation

NAA Alertness Assessment

NAA Pilot Fatigue Survey

Use this Template

Print as PDF

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.