Emergency Response Fatigue Assessment Form
Self-report your fatigue and readiness before, during, or after duty. Complete all fields for an accurate assessment.
Responder Name or ID
*
Current Role or Position
*
Please Select
Paramedic
Firefighter
Police Officer
Incident Commander
Support Staff
Other
Assessment Timing
*
Before duty
During duty
After duty
Hours of sleep/rest in the past 24 hours
*
Please Select
Less than 4 hours
4–6 hours
6–8 hours
More than 8 hours
Fatigue Symptoms Experienced (select all that apply)
*
Difficulty concentrating
Slowed reaction time
Irritability or mood changes
Physical exhaustion
None of the above
Other
Cognitive and Physical Readiness
*
Rows
Not at all ready
Somewhat ready
Fully ready
Alertness
1
2
3
Decision-making ability
4
5
6
Physical stamina
7
8
9
Have you experienced any incidents or near-misses related to fatigue in the past 24 hours?
*
No
Yes, incident
Yes, near-miss
Do you feel able to continue duty safely at this time?
*
Yes, I can continue safely
No, I do not feel safe to continue
Unsure
Do you require immediate support or intervention?
*
No support needed
Yes, medical support
Yes, supervisor support
Other support
Overall Fatigue Risk Rating
*
Low risk
1
2
3
4
High risk
5
1 is Low risk, 5 is High risk
Submit Assessment
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