Healthcare Worker Fatigue Assessment Form
Use this form to evaluate fatigue levels, workload factors, and recovery needs for healthcare workers. It uses a modern, polished design and keeps the title exactly consistent throughout.
Work Context
Job role or unit
*
Primary shift type
*
Day
Evening
Night
Rotating
On-call
Average shift length (hours)
*
Please Select
4
6
8
10
12
14
16
Other
Fatigue 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
Fatigue Indicators
*
Rows
No fatigue
Mild
Moderate
Severe
Physical exhaustion
1
2
3
4
Mental exhaustion
5
6
7
8
Reduced concentration
9
10
11
12
Recovery after rest
13
14
15
16
Has fatigue affected your performance today?
*
No
Slightly
Moderately
Significantly
Workload and Recovery
Main contributors to fatigue
*
Staffing levels
Overtime
Sleep quality
Consecutive shifts
Emotional strain
Commute length
Work environment
Other
Hours of sleep in the last 24 hours
*
Have you had a break today?
*
Yes
No
Not yet
Summary and Follow-up
Additional concerns or notes
Would you like follow-up from a supervisor or wellness contact?
*
Yes
No
Submit
Should be Empty: