Employee to complete Part 1

Part 1 Self Assessment

Manager / Supervisor to Complete Part 2 (can be completed even if part one has not been completed)

Part 2 Observation

Part 3 – Risk Evaluation

What is the level of risk associated with this person continuing without intervention? Consider the following:

§  Has a fatigue related incident occurred or is it likely to occur?

§  Has the person self reported or been identified by another person as a fatigue risk?

Circle the risk number in the matrix below after considering consequence and likelihood

If a risk to continued operation has been identified proceed to Part 4 – Supervisory Actions

Part 4 – Supervisory Actions
Suspected Issue Suggested Action
Drugs and Alcohol Refer to POL 72 – Drugs and Alcohol Policy and arrange test with the safety hotline number or Depot Manager.
Fatigue §  Consider the following and discuss with employee:

– Task rotation

– Rest break until complies with fatigue hours

– Alternative duties

§  Confirm AFM Bus operators training in TLIF 1007C (Apply fatigue management strategies)

§  Counsel operator to ensure fatigue responsibilities are being carried out

§  Report near miss using FORM 178 – Injury/Incident Form

§  Complete a Corrective Action report if further action is required, e.g. training in fatigue

§  Referral to EAP if necessary

§  If any change in bus operator health status, complete FORM 633 and inform Transport for NSW
Health or Medical problems Arrange for medical referral Refer to PROC 50.30 – Health Monitoring

Part 5 – Manager / Supervisor Sign off