Southbris Enterprises Pty Ltd Fatigue Management Plan

• Audit Title

• Conducted on

  Date

• Prepared by

• Location
  Address

• Employee full name

• Date and time of Assesment

  Date

• Are you regularly scheduled to work equal to or in excess of 8 hours per shift?

  Yes

  No

• Have you worked in excess of 8 consecutive hours during the last 24 hours?

  Yes

  No

• How many hours of consecutive work did you do in the last 24 hours?

• Have you rested for a minimum of 10 consecutive hours since completing your last shift?

  Yes

  No

• How many actual hours sleep have you had during that time?

• How many actual hours resting did you have prior to starting your last shift?

• Date & time your last commenced

  Date

• Date & time your last shift finished

  Date

• Are you regularly scheduled to work equal to or in excess of 12 hours per shift?

  Yes

  No

• Have you worked in excess of 12 consecutive hours during the last 24 hours?

  Yes

  No

• How many hours of consecutive work did you do in the last 24 hours?

• Have you rested for a minimum of 10 consecutive hours since completing your last shift?

  Yes

  No

• How many actual hours sleep have you had during that time?

• How many actual hours resting did you have prior to starting your last shift?

• Date & time your last commenced

  Date

• Date & time your last shift finished

  Date

• Are you aware of any existing circumstances, ailments, or conditions which may effect your ability to competently and safely operate the equipment within the guidelines of the applicable manufacturers operational instructions and WH&S work method statements, relevant to the safe operation of the equipment that is required?

  Yes

  No

• Detail

• I am signing as an employee of Southbris Enterprises Pty Ltd, and do here declare, that as a competent/licensed operator of the equipment within the subject of this hire, I am fully compliant with WH&S and Australian Standard Fatigue Management regulations and have, prior to presenting for this shift, attained the minimum required consecutive hours off duty time or sleep, to comply with fatigue management regulations to this worksite and as advised.

  Sign

• Full name of employee audited, and signed above

• Date

  Date

Office Use only

• Audit sighted by

• Position

• Date

  Date

• Any followup action required? If so, detail