Fatigue Report Form PURPOSE The form is used for fatigue analysis. HOW TO COMPLETE THIS FORM In sections 1 to 9, the reporting person must: • Make sure that all subjects are clearly filled up and the applicable options encircled • Submit it together with the Post-Flight Documents via File Upload • The Safety Department will acknowledge and investigate this Fatigue Report • Keep a copy for yourself. (*) Indicates the field is required1. Is confidentiality required? SelectYesNoName Employee No. 2. When did it happen? Local Date Local Time 12 AM1 AM2 AM3 AM4 AM5 AM6 AM7 AM8 AM9 AM10 AM11 AM12 PM1 PM2 PM3 PM4 PM5 PM6 PM7 PM8 PM9 PM10 PM11 PMUTC Time 12 AM1 AM2 AM3 AM4 AM5 AM6 AM7 AM8 AM9 AM10 AM11 AM12 PM1 PM2 PM3 PM4 PM5 PM6 PM7 PM8 PM9 PM10 PM11 PMSectors (e.g. DXB-BAH-LHR-DXB)Sector on which fatigue occurred: From Sector on which fatigue occurred: To Hours from report time to when fatigue occurred Aircraft Type Challenger 605Learjet 60Aircraft Registration A6-ASMA6-VGGA6-GOANot Applicable (N/A)Disrupted? YesNoNumber of Crew 3. What happened?Please check how you felt 1. Fully alert, wide awake2. Very lively, somewhat responsive, but not at peak3. OK, somewhat fresh4. A little tired, less than fresh5. Moderately tired, let down6. Extremely tired, very difficult to concentrate7. Completely exhausted4. Describe how you felt for what you observed. *5. Please rate the point that indicates how you felt. Alert Drowsy 012345678910 6. Why did it happen? 7. What did you do? Actions taken to manage or reduce fatigue (e.g. Cockpit nap):8. What could be done? Suggested Corrective Actions: 9. What happened? (check which is applicable) (Check which is applicable) Fatigued Prior to Duty YesNoWhile on Duty YesNoOthers YesNoPlease Specify Hotel YesNoIn-Flight Rest YesNoPersonal YesNoImage Upload Drop your file here or click here to upload You can upload up to 10 files. File Upload Drop your file here or click here to upload You can upload up to 1 files. ASM-SMS-F-11 WebsiteSubmit