Fatigue Notification

REF-Nr. _____________________ by FRA L/O-CF

1. NAME 2.1 PK-NR 2.2 HOMEBASE 2.3 DEPARTMENT 2.4 TEAM

3. CREW POSITION 4. TIME 5. FLT No. 5.1 TYPE OF AIRCRAFT

PII GPII PI FB

6. LEG 7. DATE 8. CREW-COMPLEMENT 9. ROTATION NUMBER

(PU) (FB)

10. PLANNED TIMES 11. ACTUAL TIMES

STD: UTC STA: UTC ATD: UTC ATA: UTC

12. PHASE
PRIOR DUTY GROUND TAKE-OFF CLIMB CRUISE DESCENT APPROACH LANDING GROUND AFTER DUTY

13. SUBJECTIVE EVALUATION OF ALERTNESS Please mark one 14. FLIGHT / ROTATION DETAILS

Length of Duty time in h/min:

1 2 3 4 5 6 7 8 9
Very Alert, Neither Sleepy, Very Leg of day:
alert normal alert, but no sleepy,
level nor effort to great
Day in rotation:
sleepy keep effort to
awake keep
awake

15. OPTIONAL FREE TEXT What happend?

16. SYMPTOMS (several markings possible – pelase add brief explanation (No. 15 above), if * items marked)
Slowed reaction time Difficulties concentrating on tasks *

Lack of energy, weakness Lapses in attention *

Repeated yawning / Heavy eye lids / Eye rubbing Failure to communicate important information *

Headaches, nausea of upset stomach Difficulty thinking clearly

Nodding / Micro sleeps *

Forgetfulness *

Emotional aspects * *

17. SUBJECTIVE REASON FOR FATIGUE (several markings possible – please add brief explanation (No. 15 above), if * items marked)
Sleep deprivation * Private involvement Workload Diversion

Time shift Commuting Inflight Rest insuff./disrupted

Structure of duty plan Insufficient rest * Medical

18. SLEEP DETAILS 19. WHAT DID YOU DO (several markings possible)
Sleep quality prior flight: GOOD FAIR POOR Caffeine
Time since awake:
Physical activity
Sleep in last 24h:

Sleep in last 48h: