Shift Worker Fatigue Assessment Form
Complete this form to assess current fatigue levels and risk factors before your shift.
Full Name
*
First Name
Last Name
Shift Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shift Start Time
*
Hour Minutes
AM
PM
AM/PM Option
How many hours have you slept in the last 24 hours?
*
Rate your current level of fatigue
*
Not at all fatigued
1
2
3
4
5
6
7
8
9
Extremely fatigued
10
1 is Not at all fatigued, 10 is Extremely fatigued
How alert do you feel right now?
*
Very drowsy
1
2
3
4
5
6
7
8
9
Very alert
10
1 is Very drowsy, 10 is Very alert
Have you consumed any of the following in the past 6 hours?
*
Caffeine (coffee, tea, energy drink)
Alcohol
None
In the last week, how many night shifts have you worked?
*
Select any symptoms you are currently experiencing
*
Difficulty concentrating
Irritability
Microsleeps (brief involuntary sleep)
None of the above
Have you had any unplanned naps in the last 24 hours?
*
Yes
No
Submit Assessment
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