Observation and Fatigue Assessment Record
Observation and Fatigue Assessment Record
WHS-011-FRM
This form is a record of the fatigue assessment for a person under AquawestFatigue Management Procedure. The privacy and confidentially of that person will be maintained with respect to the information gained as a result of the fatigue assessment.
If any person has difficulty with completing assessment seek advice from your supervisor.
OBSERVATION and FATIGUE ASSESSMENT RECORDSection 1 - Assessment Type Tick appropriate boxes
Assessment Type: Self Random Reasonable Suspicion With Cause
Section 2 - Particulars of Person (being assessed) and Work Schedule
Engagement Type: Worker (Employee) Worker (Contractor)
If Worker what Organisation: ......
Surname: ...... First Name: ......
Job Role: ......
Nature of Duties: ......
......
Date: ...... /...... /...... Time: ...... : ...... hrs Attendance Start Time: ...... : ...... hrs
Work Schedule: Planned Extended Hours
This assessment was undertaken ……….. Hrs into the attendance.
Yes / No
Will this work carry you over 12 hours for the shift?
Have you had a 10 hour break since you last worked?
Do you consider yourself fit for work to be carried out?
CRITERIA / HRS / POINTS
(X) No of Hours Sleep in the Past 24 Hours
1 / Sleep / 2 Hrs / 3 Hrs / 4 Hrs / 5 + Hrs
Points / 12 / 8 / 4 / 0
(Y) No of Hours Sleep in the Past 48 Hours
2 / Sleep / 8 Hrs / 9 Hrs / 10 Hrs / 11 Hrs / 12 + Hrs
Points / 8 / 6 / 4 / 2 / 0
TIME AWAKE SINCE LAST SLEEP
(Z) Add one point per hour awake greater than sleep in step 2
SCORE (add total points)
For example, using a point system may assist in determining what course of action an individual and/or organisation may take. A simple point system could be something like the following:
Example – Low Fatigue
If I have slept 6 hours in the prior 24 hours, and 10 hours in the prior 48 hours and have been awake for 2 hours I have
X=6 (sleep in prior 24 hours); Y=10 (sleep in prior 48 hours) and Z=2 (hours awake)
Points System
Step 1 + Step 2 + Step 3 = Fatigue Risk Score
0 + 4 + 0 = 4
Example – Higher Fatigue
If I have slept 3 hours in the last 24 hours, and 6 hours in the prior 48 hours and have been awake for 10 hours I have;
X=3 (sleep in prior 24 hours); Y=6 (sleep in prior 48 hours) and Z=10 (hours awake)
Points System
Step 1 + Step 2 + Step 3 = Fatigue Risk Score
8 + 8 + 4 = 20
FEELING / SCORE / ACTIONFully Alert / Less than 1 / No Action
Okay / 1-4 / Personal Monitoring
Moderately Tired / 5-8 / Assess Risk for activity being undertaken. Advise Supervisor
Completely Exhausted / 9+ / Advise Site Supervisor. DO NOT Commence work.
Reason for Fatigue:
Action Required
Employee Signature:
Date:
Supervisor Signature:
Date:
Appendix 1 – Sign and Symptoms of Fatigue
PHYSICAL / MENTAL / EMOTIONALYawning / Difficulty concentrating on a task / More quiet than
usual
Heavy Eyelids / Lapses in attention / Lacking energy
Eye-rubbing / Difficulty remembering what you are doing / Mood changes,
decrease tolerance
Head drooping / Failure to communicate important
information / Emotional outburst,
aggressive, rage
Micro sleeps / Failure to anticipate events or actions
Accidentally doing the wrong thing
(error)
Accidentally not doing the right thing
(omission)
Use these signs and symptoms for Fatigue when completing a Fatigue Assessment.
Appendix 2 – Prior Sleep Wake Model
This tool is used for qualifying a person’s fatigue risk level/s based on the amount of sleepobtained in the prior 24 and 48 hour period.
The basis of the model is minimum sleep of:
• 5 hours in the previous 24 hour period and
• 12 hours in the previous 48 hour period.
Start of Shift End of Shift
Wake up
/ Sleep / Sleep / WorkX
Y
Z
X = Sleep in prior 24 hrs
Y = Sleep in prior 48 hrs
Z = Time Awake
As prior sleep decreases and prior wake increases the likelihood of fatigue also increases.
In general; X should be greater than threshold of 5 hours
Y should be greater than threshold of 12 hours
Z should be less than Y
Version No 1 / Issue Date: April 2014 / Page 1 of 3Document Deemed Uncontrolled When Printed