Retail Worker Fatigue Assessment Form
Complete this form to help evaluate fatigue, contributing factors, and immediate work impact in your retail work setting.
How would you rate your current level of fatigue?
*
1
2
3
4
5
How many hours did you sleep in the last 24 hours?
*
Less than 4 hours
4-6 hours
6-8 hours
More than 8 hours
How demanding has your workload been during this shift?
*
Not demanding
1
2
3
4
Extremely demanding
5
1 is Not demanding, 5 is Extremely demanding
How long is your current shift?
*
Less than 4 hours
4-6 hours
6-8 hours
More than 8 hours
How often have you taken breaks during this shift?
*
No breaks
One break
Two breaks
More than two breaks
Please indicate if you are currently experiencing any of the following physical symptoms:
*
Headache
Muscle aches
Eye strain
None of these
Other
How would you rate your current ability to focus on tasks?
*
Very poor
1
2
3
4
Excellent
5
1 is Very poor, 5 is Excellent
Have there been any recent changes in your work schedule or duties?
*
Yes
No
In the table below, please indicate how often you have experienced each of the following during this shift.
*
Rows
Never
Rarely
Sometimes
Often
Feeling drowsy
1
2
3
4
Losing concentration
5
6
7
8
Making mistakes
9
10
11
12
Feeling irritable
13
14
15
16
Briefly describe how your current fatigue level is affecting your work performance.
*
Submit Assessment
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