Employee Fatigue Risks Management

EMPLOYEE FATIGUE RISKS MANAGEMENT

Purpose and Scope

This document establishes the organization’s approach to identifying, assessing, controlling and monitoring fatigue-related risks affecting employee health, safety and performance. It applies to all employees, contractors and any worker whose duties include safety-sensitive activities or work outside standard daytime hours.

Personal Information

Position Information

Employment History (Most Recent)

Education

Professional References (3)

Fatigue Risk Assessment - Work Pattern

Typical shift start time:    Typical shift end time:

Average hours per shift:    Shifts per week:    Night shifts per month:

Fatigue Risk Factors and Medical / Personal Disclosures

Do you currently suffer from a sleep disorder or condition that affects alertness?   Yes   No

Are you currently taking any prescription medications that may impair alertness?   Yes   No

Controls, Procedures and Reporting

Control measures applied to mitigate fatigue risks include scheduling limits, mandatory rest breaks, staff rotation, controlled overtime authorization, and access to fatigue education and support. The organization retains the right to require medical assessment or fitness-for-duty evaluation where operational risk is identified.

Fatigue Risk Checklist (To be completed by employee and supervisor)

Employee has worked extended hours (>12 hours) within the last 72 hours.
Employee has worked consecutive night shifts exceeding recommended limits.
Employee reports hours between shifts or inadequate rest.
Long commute or hazardous travel conditions after shift.
Other identified risk factors requiring action:

Training, Monitoring and Review

Employees will complete mandated fatigue awareness training. Supervisors will monitor compliance with scheduling controls and investigate fatigue-related incidents. This policy will be reviewed periodically and after any fatigue-related incident or near-miss to ensure continued effectiveness.

Legal Disclosures and Policies

At-Will Employment: Nothing in this form alters any at-will employment relationship unless expressly documented in a separate written agreement signed by an authorized representative of the organization.

Equal Opportunity: The organization provides equal employment opportunity in accordance with applicable law. Disclosures of medical conditions or treatments will be handled confidentially and in accordance with legal obligations.

Authorizations and Certifications

Authorization to Contact: I authorize the organization to contact my previous employers and listed references for the purpose of verifying employment history, fitness for duty and safety-related performance.

Consent to Health Assessment: I consent to reasonable fitness-for-duty evaluations, medical screening, or referral for clinical assessment when required to manage fatigue-related risk. Such assessments will be limited to information relevant to job safety and fitness.

Applicant Certification: I certify that all information provided in this form is true, accurate and complete to the best of my knowledge. I understand that failure to disclose material information related to fatigue risk factors, sleep disorders, or medications that impair alertness may result in removal from safety-sensitive duties pending further assessment.

I acknowledge receipt of the Fatigue Risks Management information and agree to comply with scheduling, reporting and control procedures described herein.

I authorize the organization to conduct background checks, including verification of safety-sensitive employment history, consistent with law.

Records and Confidentiality

All records created under this program, including any medical or assessment records, will be maintained securely, access limited to authorized personnel, and used only for legitimate health, safety and employment purposes.

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