Driver Fatigue Monitoring Checklist Form
Use this form to assess and document driver alertness and fatigue risk before starting a trip.
Driver Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Vehicle or Route Information
*
Observer/Supervisor Name
*
First Name
Last Name
Checklist: Please indicate if the driver is showing any of the following signs of fatigue.
*
Rows
Yes
No
Yawning frequently
1
2
Slow reaction times
3
4
Difficulty focusing or keeping eyes open
5
6
Frequent blinking or rubbing eyes
7
8
Drifting out of lane
9
10
Difficulty remembering last few miles driven
11
12
How many hours did the driver sleep in the last 24 hours?
*
Has the driver taken a break in the last 2 hours?
*
Yes
No
Self-assessment: How alert does the driver feel right now?
*
Very Drowsy
1
2
3
4
Fully Alert
5
1 is Very Drowsy, 5 is Fully Alert
Supervisor/Observer's overall assessment of driver's fitness to drive
*
Fit to drive
Not fit to drive
Fit to drive with caution
Comments or recommendations (if any)
Submit Checklist
Should be Empty: