Factory Operations Fatigue Assessment Form
Please complete this form to assess fatigue levels and contributing factors in factory operations.
Full Name
*
First Name
Last Name
Shift Type
*
Day
Evening
Night
Rotating
Other
How many hours did you sleep in the last 24 hours?
*
How alert do you feel right now?
*
Not alert at all
1
2
3
4
5
6
7
8
9
Extremely alert
10
1 is Not alert at all, 10 is Extremely alert
Please rate the following fatigue symptoms experienced during your shift.
*
Rows
Not at all
Mild
Moderate
Severe
Difficulty concentrating
1
2
3
4
Yawning
5
6
7
8
Heavy eyelids
9
10
11
12
Slowed reaction time
13
14
15
16
Irritability
17
18
19
20
In the past week, how often have you felt too tired to complete your tasks safely?
*
Never
Rarely
Sometimes
Often
Always
Which of the following factors do you believe contributed to your fatigue during this shift? (Select all that apply)
*
Long working hours
High workload
Repetitive tasks
Poor lighting
Noise
Temperature extremes
Other
How would you rate your overall work environment today?
*
1
2
3
4
5
Have you taken any breaks during your shift?
*
Yes
No
Please provide any additional comments or observations related to fatigue or your work environment.
Submit Assessment
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