Please enter the details of the report below and submit

    Member Details

    WHEN DID IT HAPPEN?
    Where applicable

    YesNo
    Fulltime75% Part Time50% Part Time
    747332333787A380

    HOW DID YOU FEEL

    Fully alert, wide awakeVery lively, somewhat responsive but not peakOK, somewhat freshA little tired, less than freshModerately let down, tiredExtremely tired, difficult to concentrateCompletely exhausted

    WHY DID IT HAPPEN?

    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo

    WHAT DID YOU DO?

    WHAT RISK WAS THERE?

    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo

    WHAT COULD BE DONE:

    This report does not cancel your obligation to report to your employer. You will need to submit a fatigue report to your employer in addition to submitting this report.