Driver Fatigue Self-Assessment Form

Pre-shift self-assessment for drivers to evaluate sleep, alertness, and fatigue risk before operating, with a clear go/no-go decision and dispatch follow-up when needed.

Shift and Driver Details

• Driver name
  Enter your full name for dispatch follow-up and audit trail.
• Employee ID
  Use your company employee or operator ID.
• Shift date
  Select the date of the shift you are about to start.
• Shift start time
  Enter your scheduled start time.
• Route or assignment
  Optional. Enter the route number, run ID, or assignment name if needed for dispatch.

Sleep and Rest

• How many hours did you sleep in the last 24 hours?
  Enter a whole or decimal number of hours slept.
• How would you rate your sleep quality?
• Was your sleep interrupted or shortened?
• Briefly describe the interruption or reason for shortened sleep
  Shown only if you answered Yes. Keep details brief and job-related.
• Hours since your last meaningful rest break
  Enter the number of hours since your last meaningful rest period.

Alertness and Fatigue Check

• How alert do you feel right now?
• Which fatigue symptoms are you experiencing?
• Have you taken any medication, alcohol, or other substance that may affect safe driving?
• Briefly describe the substance or medication concern
  Shown only if you answered Yes. Do not include unnecessary medical details.

Go / No-Go Decision

• Based on this self-assessment, are you fit to operate safely?
• Reason for no-go decision
• Additional details for dispatch
  Shown only if you selected No-Go. Provide a brief, job-related explanation.
• Have you notified dispatch or your supervisor?

Acknowledgment and Consent

• I understand this self-assessment is non-punitive and is intended to support safe operations.
• I consent to the collection and use of this information for dispatch review, safety follow-up, and audit trail purposes.
  Only minimum-necessary information will be used for operational safety and compliance.
• Signature
  Sign to confirm the information provided is accurate to the best of your knowledge.