Fitness for Duty Form Template

Use this Fitness for Duty Form Template to confirm a worker is fit for duty before a shift, covering rest, impairment, physical and mental readiness, sign-off.

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Health & Safety
Fitness for Duty Form Template

Worker And Shift Details

Rest And Recovery

Impairment And Substances

Physical Readiness

Mental Readiness

Task And Equipment Readiness

Declaration And Review

Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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Fitness for Duty Form Template

Use this Fitness for Duty Form Template to confirm a worker is fit for duty before a shift, covering rest, impairment, physical and mental readiness, sign-off.

1. Worker name, role, and shift start time are recorded

2. The task or work area for this shift is recorded

3. Safety-critical duties assigned for this shift are identified

1. The minimum rest period since the previous shift has been met

2. The worker has not exceeded the maximum consecutive shifts allowed by the roster

3. The worker confirms they feel adequately rested for the shift ahead

4. Any overtime, shift swap, or on-call period since the last shift is recorded

1. The worker confirms they are not under the influence of alcohol

2. The worker confirms they are not under the influence of any illegal substance

3. The worker has checked that any medication taken does not impair safe working

4. The worker knows how to report a medication change affecting their fitness for duty

1. The worker confirms no injury or illness prevents safe performance of the task

2. Any existing medical restriction or workplace accommodation is being followed

3. Corrective eyewear or hearing aids required for the role are present and in use

4. The worker has had adequate food and water before starting the shift

1. The worker confirms they can concentrate on the task for the full shift

2. The worker confirms no personal circumstance is affecting their ability to work safely

3. The worker knows how to raise a concern about their own fitness without penalty

4. The worker knows how to report a colleague who appears unfit for duty

1. The worker holds current training or certification required for the task

2. Required PPE is available, correctly fitted, and in serviceable condition

3. The worker has been briefed on task-specific hazards and controls for this shift

1. The worker has signed the fitness for duty declaration

2. A supervisor has assessed the worker for visible signs of impairment or fatigue

3. Any declared restriction has been actioned with work adjusted or reassigned