Form
Form - Fatigue Self-Report and Officer Response
Document FSSMS-FRM-03Stage 2Revision 3Version 0.3.3
Topic pages open on your jurisdiction, and requirements tables show its line. You can change this on any page.
Three parts on one form, used under Policy - Fatigue and Hours of Work. Part A is the member’s own report that they are too fatigued to perform a task or to drive safely (or a report about another member); Part B is the officer’s response; Part C, on a separate sheet, is the officer’s record of a fitness-for-duty observation on reasonable grounds, used only when an officer believes a member may be impaired from any cause. A good-faith report under Part A carries no penalty of any kind: no discipline, no loss of pay for the shift, no loss of a volunteer point or credit (policy 5.3.2). Fatigue is managed as a hazard under the employer’s general duty in the applicable OHS statute (J02 Duties of Employers, Supervisors, Workers and Contractors), and impairment from any cause under a fitness-for-duty approach consistent with the national standard (CSA Z1008:21), with support and accommodation before discipline for disclosure, as human rights law requires (J33 Return to Work, Accommodation and Hours of Work). A fatigue risk management system treats self-reporting without penalty as a core control (AFAC, 2022). The form may be completed on paper, by phone with the officer writing it, or in the app; the officer enters it the same shift. Parts A and B go to the health and safety officer and never into a personnel file; Part C goes to the senior officer responsible for health and safety and the occupational health provider.
| Field | Entry |
|---|---|
| Date and time of report | |
| Member making the report (identifier, role, station; career or volunteer) | |
| Report is about: myself; another member (identifier) | |
| Context: on shift; at an incident (incident number); at training; responding from home; deployment; other | |
| Hours awake at the time of the report (approximate) | |
| Hours on duty this period, including overtime and call-backs | |
| Consecutive shifts or calls in the last 48 hours; sleep obtained in the last 24 and 48 hours (approximate) | |
| For volunteers: calls attended since 2200 last night (hours); day job start time today | |
| The task, assignment or driving I believe I should not do right now | |
| Signs noticed (any): difficulty staying awake; slow reactions; errors or near misses; irritability; difficulty concentrating; headache; other | |
| Declaration: I believe I am too fatigued to perform this task or to drive safely (or: I believe the member named is) | Yes |
| Member signature or spoken confirmation recorded by the officer (name of role, time) |
| Field | Entry |
|---|---|
| Officer (role, station) and time the report was received | |
| Acknowledged to the member (time; words used, for example “thank you, you are off the task”) | |
| Action taken: removed from the task; removed from the driver’s seat; both | |
| Rest arranged: where; from what time; for how long (minimum per policy 5.2.2 after a protracted incident) | |
| Relief arranged: who; by what time; apparatus or crew status meanwhile (in service, out of service, reassigned) | |
| Rested driver assigned for any vehicle movement (role) | |
| If an emergency response could not wait and the member had to be used: controls applied (second member awake in the cab, reduced speed, shortest route) and the reason recorded | |
| Return to duty: time; confirmed by the officer with the member; any further rest or stand-down ordered | |
| Confirmation: no adverse consequence (pay, points, credit, standing, assignment) results from this report | Yes |
| Forwarded to the health and safety officer (date) | |
| Officer signature and date | |
| Member told the outcome and how the report will be used (aggregate only) (date) |
Part C: Fitness-for-duty observation on reasonable grounds (separate sheet; use only when an officer believes a member may be impaired from any cause)
| Field | Entry |
|---|---|
| Date, time, location | |
| Member (identifier, role, station) | |
| Observing officer (role) and second observer where available (role) | |
| Observations, in plain facts (speech; balance and coordination; odour; eyes; behaviour and judgement; errors; the member’s own statements). No diagnosis, no speculation about cause | |
| Member’s account, if offered (the member is not required to give one) | |
| Immediate action: removed from safety-sensitive work (time); not permitted to drive; equipment and crew reassigned | |
| Safe transport home arranged (how; by whom; time); never by the member driving | |
| Referral to the occupational health provider for assessment (date and time of referral) | |
| Member told: this is a fitness-for-duty process, not discipline; disclosure of a health, sleep, medication or substance concern leads to support and accommodation; conduct is a separate process under Policy - Internal Responsibility and Accountability 5.4 | Yes |
| Union or association representative offered (yes; declined; not applicable) | |
| Forwarded to the senior officer responsible for health and safety (date); copy to no one else | |
| Officer signature and date; second observer signature where available |
| Month | Reports (Part A) by station | By shift or time of day | By career and volunteer | Officer response within the same shift (count) | Rest or relief provided (count) | Vehicle movements avoided (count) | Part C observations (count only) | Referred to the Health, Wellness and Rehab team and the JOHSC (date) |
|---|---|---|---|---|---|---|---|---|
| Field | Type | Required | Who completes |
|---|---|---|---|
| Date and time of report | Date and time | Yes | Member or officer |
| Member identifier, role, station, status | Text | Yes | Member or officer |
| About self or another member | Choice | Yes | Member |
| Context | Choice and incident number | Yes | Member or officer |
| Hours awake; hours on duty; consecutive shifts or calls; sleep | Numbers, approximate | Yes | Member |
| Volunteer night calls and day job start | Numbers and time | Volunteers only | Member |
| Task or driving concerned | Text | Yes | Member |
| Signs noticed | Multiple choice | Optional | Member |
| Declaration | Yes | Yes | Member |
| Member confirmation | Signature or recorded spoken confirmation | Yes | Member; officer records if by phone |
| Officer, time received | Text and time | Yes | Officer |
| Acknowledgement | Time and words | Yes | Officer |
| Action taken | Choice | Yes | Officer |
| Rest and relief arrangements | Text and times | Yes | Officer |
| Rested driver | Role | Yes where a vehicle moves | Officer |
| Emergency-use controls and reason | Text | Only where the member had to be used | Officer |
| Return to duty | Time and text | Yes | Officer with the member |
| No adverse consequence confirmation | Yes | Yes | Officer |
| Forwarded to HSO | Date | Yes | Officer |
| Officer signature; member told outcome | Signature; date | Yes | Officer |
| Part C observations | Facts in text | Yes when Part C is used | Observing officer; second observer |
| Part C immediate action; safe transport; referral | Text, times, date | Yes when Part C is used | Observing officer |
| Part C member told; representative offered | Yes; choice | Yes when Part C is used | Observing officer |
| Part C forwarded to the senior officer responsible for health and safety | Date | Yes when Part C is used | Observing officer |
| Part D monthly collation | Counts | Monthly | Health and safety officer |
Retention. Parts A and B: held by the health and safety officer for two years, then destroyed; the monthly aggregate retained 10 years. Part C: held by the senior officer responsible for health and safety for the member’s service plus two years or as counsel directs; never in a personnel file; the clinical assessment stays with the occupational health provider, who reports only fit, unfit or fit with restrictions (Policy - Records, Privacy and Health Information). Privacy. Reports are reported only in aggregate, by station, shift and time of day; no report is reported by name; Part C contains observations of fact and no diagnosis.
This chapter relies on the following legal requirements, which differ by province and territory. Check your jurisdiction’s section on each topic page before adopting it.
| Topic | What to check in your jurisdiction | Page |
|---|---|---|
| Duties of Employers, Supervisors, Workers and Contractors | The employer’s general duty under which fatigue is managed as a hazard, and the worker’s duty to take reasonable care and report hazards, which this self-report discharges | J02 Duties of Employers, Supervisors, Workers and Contractors |
| Right to Refuse and Reprisal Protection | Protection from reprisal for raising a concern or exercising a right under the OHS statute, the complaint route, and who bears the burden of proof (the no-penalty confirmation in Part B) | J07 Right to Refuse and Reprisal Protection |
| Volunteer Firefighters | Whether volunteers benefit from the heart injury presumption, and the participation or other conditions they must meet | J11 Volunteer Firefighters |
| Workers’ Compensation and Firefighter Presumptions | The heart injury presumption for firefighters: the qualifying event, the time window and any service minimum (post-incident rest is recorded in Part B) | J32 Workers' Compensation and Firefighter Presumptions |
| Return to Work, Accommodation and Hours of Work | The human rights duty to accommodate disability, including substance dependence, to the point of undue hardship; the bona fide occupational requirement test; and any hours-of-work or fatigue rules that reach firefighters | J33 Return to Work, Accommodation and Hours of Work |
Australasian Fire and Emergency Service Authorities Council [AFAC]. (2022). Managing fatigue in emergency response (Version 2). https://www.afac.com.au/resources/managing-fatigue-in-emergency-response
CSA Group. (2021). CSA Z1008:21, Management of impairment in the workplace. https://www.techstreet.com/standards/csa-z1008-21?product_id=2221471