Driver Safety Fatigue Assessment Form
Use this form to assess driver fatigue risk, recent rest, and current readiness to drive safely.
Driver Information and Trip Context
Driver Name
*
First Name
Last Name
Role / Department or Vehicle Assignment
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Planned Trip or Shift Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Fatigue Assessment Inputs
Last sleep duration (hours)
*
Sleep quality
*
Very poor
Poor
Fair
Good
Very good
Hours worked in the last 24 hours
*
Hours since last significant break or rest
*
Safety Check and Outcome
Current fatigue indicators
*
Rows
None
Mild
Moderate
Severe
Yawning
1
2
3
4
Heavy eyes
5
6
7
8
Reduced concentration
9
10
11
12
Microsleeps
13
14
15
16
Slowed reaction
17
18
19
20
Readiness decision
*
Fit to drive
Fit to drive with caution
Not fit to drive
Assessor remarks / follow-up actions
Submit
Should be Empty: