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Run: Driver Fatigue Self-Assessment Form

A pre-shift Driver Fatigue Self-Assessment Form for checking sleep, alertness, medication effects, and fit-for-duty before a route starts. Use it to make a c...

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Shift and Driver Details

Driver name (required)

Enter your full name for dispatch follow-up and audit trail.

Employee ID (required)

Use your company employee or operator ID.

Shift date (required)

Select the date of the shift you are about to start.

Shift start time (required)

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? (required)

Enter a whole or decimal number of hours slept.

How would you rate your sleep quality? (required)

Was your sleep interrupted or shortened? (required)

Briefly describe the interruption or reason for shortened sleep (required)

Shown only if you answered Yes. Keep details brief and job-related.

Hours since your last meaningful rest break (required)

Enter the number of hours since your last meaningful rest period.

Alertness and Fatigue Check

How alert do you feel right now? (required)

Which fatigue symptoms are you experiencing? (required)

Have you taken any medication, alcohol, or other substance that may affect safe driving? (required)

Briefly describe the substance or medication concern (required)

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? (required)

Reason for no-go decision (required)

Additional details for dispatch (required)

Shown only if you selected No-Go. Provide a brief, job-related explanation.

Have you notified dispatch or your supervisor? (required)

Acknowledgment and Consent

I understand this self-assessment is non-punitive and is intended to support safe operations. (required)

Yes No N/A

I consent to the collection and use of this information for dispatch review, safety follow-up, and audit trail purposes. (required)

Only minimum-necessary information will be used for operational safety and compliance.

Yes No N/A

Signature (required)

Sign to confirm the information provided is accurate to the best of your knowledge.

Get your results

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Email (required)

Your name (optional)

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