Chapter 6 - Appendices

Attach any supporting documents here. This may include:

  • Relevant safety manuals
  • Relevant CARs or guidance notes from Transport Canada
  • Sleep diary form for collecting data
  • Symptom checklist
  • Description of the fatigue occurrence reporting form or database
  • Additional reading material that may be of particular interest to employees

Points to Consider

  • Is there any information that users of the FRMS manual will require easy access to?

Sleep Diary

Sleep Diary – FRMS Study

Month & Year: ..............................      Name: ........................................

  Start Date/ Time ddhhmm Pre-sleep Fatigue Level End Time hhmm Post-sleep Fatigue Level Sleep Quality Remarks
eg 27 1400 1 2 3 4 5 6 7 2130 1 2 3 4 5 6 7 1 2 3 4 5 6 Broken sleep due to sick child
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Fatigue Level

  1. Fully alert, wide awake
  2. Very lively, responsive, but not at peak
  3. Okay, somewhat fresh
  4. A little tired, less than fresh
  5. Moderately tired, let down
  6. Extremely tired, difficulty concentrating
  7. Completely exhausted, unable to function effectively


Qualité du sommeil

  1. Very good
  2. Good
  3. Average
  4. Poor
  5. Very poor
  6. Did not sleep

Instructions

  1. Please complete a single line of the sleep diary for each attempted or actual sleep period (i.e., major sleeps and naps) even if you do not actually fall asleep.

  2. Record start date/time and pre-sleep fatigue level immediately prior to "lights out." Start time is the time that you start attempting to sleep (i.e., "lights out") not the time that you fall asleep.

    Note: start/end times should not include time spent reading, watching TV, etc.

  3. Record end time and post-sleep fatigue level approximately 20 minutes after the sleep period ends. End time is the time that you get up or start reading, watching TV, etc., in bed. It may differ from wake up time.

  4. Rate the quality of your sleep compared to a "normal" sleep period.

  5. Make any relevant comments (e.g., regarding the sleep environment, interruptions, ambient noise, etc.).


 

Symptom Checklist

Name: ............................   Date:....................   Circle: Pre/Post Shift

Fatigue-related Symptoms

Checkbox Physical Checkbox Mental Checkbox Emotional
Checkbox Yawning Checkbox Difficulty concentrating Checkbox More quiet or withdrawn than normal
Checkbox Heavy eyelids Checkbox Lapses in attention Checkbox Lacking in energy
Checkbox Eye-rubbing Checkbox Difficulty remembering what you are doing Checkbox Lacking in motivation to do the task well
Checkbox Head drooping Checkbox Failure to communicate important information Checkbox Irritable or grumpy behaviour
Checkbox Micro-sleeps Checkbox Failure to anticipate events or actions Checkbox Other
Checkbox Other Checkbox Accidentally doing the wrong thing (error)    
    Checkbox Accidentally not doing the right thing (omission)    
    Checkbox Other    
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