Pilot Health Fatigue Assessment Form
Complete this assessment to help identify potential fatigue risks before or after flight duty. All responses are focused on pilot health and fatigue screening.
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessment Timing
*
Pre-flight
Post-flight
How many hours of sleep did you have in the last 24 hours?
*
Less than 4 hours
4-6 hours
6-8 hours
More than 8 hours
How would you rate your current level of alertness?
*
1
2
3
4
5
Please indicate how much you agree with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel physically tired
1
2
3
4
5
I find it hard to concentrate
6
7
8
9
10
I feel drowsy or sleepy
11
12
13
14
15
I have difficulty remembering instructions
16
17
18
19
20
Have you consumed any caffeine in the last 6 hours?
*
Yes
No
Have you taken any medication that may affect alertness in the last 24 hours?
*
Yes
No
How would you rate your workload during this duty period?
*
1
2
3
4
5
Are you experiencing any symptoms that could indicate fatigue (such as yawning, eye strain, or slowed reaction time)?
*
Yes
No
Submit Assessment
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