Employee Wellness Fatigue Assessment Form
Complete this form to assess employee fatigue, wellness, and work impact. Use the same title exactly across the form.
Employee Fatigue Profile
Department/Team
*
Job Role
*
Work Schedule Pattern
*
Please Select
Day Shift
Night Shift
Rotating Shift
Hybrid
Remote
Other
Fatigue and Wellness Assessment
Current fatigue level
*
No fatigue
1
2
3
4
5
6
7
8
9
Extreme fatigue
10
1 is No fatigue, 10 is Extreme fatigue
Sleep quality over the past 7 days
*
Very poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very poor, 10 is Excellent
Workload manageability
*
Not manageable
1
2
3
4
5
6
7
8
9
Very manageable
10
1 is Not manageable, 10 is Very manageable
Stress level
*
Very low
1
2
3
4
5
6
7
8
9
Very high
10
1 is Very low, 10 is Very high
Common fatigue indicators
*
Rows
Never
Rarely
Sometimes
Often
Always
Difficulty concentrating
1
2
3
4
5
Daytime sleepiness
6
7
8
9
10
Low energy
11
12
13
14
15
Headaches
16
17
18
19
20
Irritability
21
22
23
24
25
Reduced motivation
26
27
28
29
30
Impact and Follow-up
How is fatigue affecting your work performance or safety?
*
No noticeable impact
Minor impact on focus or productivity
Moderate impact on performance or safety awareness
Significant impact requiring immediate support
Prefer not to say
Comments, contributing factors, or support needed (optional)
Submit
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