Night Shift Risk Assessment Form
Evaluate employee readiness and workplace hazards prior to starting a night shift.
Shift Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shift Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Employee Role
*
Please Select
Operator
Supervisor
Maintenance
Security
Other
How would you rate your current level of fatigue?
*
Fully alert
1
2
3
4
Extremely fatigued
5
1 is Fully alert, 5 is Extremely fatigued
How prepared do you feel to begin your night shift?
*
Very prepared
Somewhat prepared
Neutral
Somewhat unprepared
Very unprepared
Potential Hazards Exposure Assessment
*
Rows
Not Present
Low
Moderate
High
Slips/Trips/Falls
1
2
3
4
Exposure to hazardous substances
5
6
7
8
Fatigue-related risks
9
10
11
12
Equipment malfunction
13
14
15
16
Lone working
17
18
19
20
Are all required safety controls in place for this shift?
*
Yes, all controls are in place
Some controls are in place
No, controls are missing
If controls are missing, please specify which ones:
Overall, what is your perceived risk level for this night shift?
*
Low
Moderate
High
Submit Assessment
Should be Empty: