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Fatigue / Fit-for-Work Declaration

Complete at the start of each shift — worker self-assessment and supervisor review

Company logo

PAGE 1 OF 2

Worker Details

Name

Position / role

Date

Site / location

Shift start time

Shift end time

Fatigue Assessment

Answer each question honestly. If any answer indicates a risk, discuss with your supervisor before starting work.

#	Question	Answer
Sleep & Rest
1	Hours of sleep in the last 24 hours
2	Hours of sleep in the last 48 hours
3	Hours since last sleep
Shift & Roster
4	Current shift length (hours)
5	Consecutive days worked
6	Time since last day off
Impairment
7	Have you consumed alcohol in the last 12 hours?	Yes / No
8	Are you taking any medication that may affect your ability to work safely?	Yes / No
9	Do you feel fatigued, drowsy or unwell?	Yes / No

If Yes to Q8 — Medication Details

Fatigue / Fit-for-Work Declaration — Page 2 of 2

Name

Date

Fitness Declaration

I declare that I am fit for work and not impaired by fatigue, illness, medication, alcohol or other substances. I have answered all questions truthfully. I understand that if my condition changes during the shift, I must report it to my supervisor immediately.

Worker Sign-off

Signature

Print name

Date & time

Supervisor Assessment

Does the worker appear fit for work? Yes No

If No — Action Taken

Stood down Reassigned to lower-risk duties Medical assessment arranged Other: _______________

Supervisor Notes

Supervisor Sign-off

Signature

Print name

Date & time