Construction Site Fatigue Assessment Form
Evaluate your current level of fatigue and alertness on site. Please answer honestly to help ensure a safe and productive work environment.
Name (First and Last)
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shift Type
*
Day shift
Evening shift
Night shift
Rotating shift
How many hours have you worked in the past 24 hours?
*
How many breaks have you taken during this shift?
*
Fatigue Symptoms Checklist
*
Rows
Never
Rarely
Sometimes
Often
Always
I feel drowsy or sleepy during work
1
2
3
4
5
I have trouble concentrating
6
7
8
9
10
I make more mistakes than usual
11
12
13
14
15
I feel physically exhausted
16
17
18
19
20
I have difficulty remembering instructions
21
22
23
24
25
On a scale of 1 to 10, how alert do you feel right now?
*
Not alert
1
2
3
4
5
6
7
8
9
Extremely alert
10
1 is Not alert, 10 is Extremely alert
How well did you sleep last night?
*
Very poorly
Poorly
Fair
Well
Very well
Have you experienced any near-misses or safety concerns today?
*
Yes
No
Additional Comments (optional)
Submit Assessment
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