Sandbox:survey: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
 
(3 intermediate revisions by the same user not shown)
Line 1: Line 1:
_NOTOC_
__NOTOC__
==Questions==
==Questions==
===General Questions===
===General===
'''*What kind of health care professional are you?'''
* '''What kind of health care professional are you?''' ❑Physician ❑Registered Nurse ❑Advanced Practice Nurse ❑Other - Please specify __________________
❑Physician
* '''What is your area of specialty?''' ❑Internal Medicine ❑Pediatrics ❑Surgery ❑Urology ❑Obstetrics & Gynecology ❑Radiology ❑Anesthesia ❑Family Medicine ❑Ophthalmology
❑Registered Nurse
* '''What is your level of training? (Physicians)''' ❑Student ❑Intern ❑Resident ❑Fellow ❑Attending
❑Advanced Practice Nurse
* '''How old are you (years)?'''❑<25 ❑25 to 30 ❑30 to 35 ❑35 to 40 ❑40 to 45❑45 to 50 ❑50 to 55 ❑55 to 60 ❑>60
❑Other - Please specify __________________
* '''Gender?''' ❑Male ❑Female ❑Do not wish to disclose


'''*What is your area of specialty?'''
=== Work Hours ===
❑Internal Medicine
* '''How many hours do you work per week?''' _____
❑Pediatrics
* '''What is the duration of your longest shift in the past week (in hours)? ______'''
❑Surgery
* '''What is the duration of your longest shift in the past month (in hours)? ______'''
❑Urology
* '''What is the duration of your longest shift in the past year (in hours)? ______'''
❑Obstetrics & Gynecology
❑Radiology
❑Anesthesia
❑Family Medicine
❑Ophthalmology


'''*What is your level of training? (Physicians)'''
=== '''Sleep Habits''' ===
❑Student
* '''How many hours do you currently sleep per day (on average)?''' _____
❑Intern
* '''How many hours did you sleep per day before entering the medical profession?''' _____
❑Resident
❑Fellow
❑Attending


'''*How many hours do you work per week?''''
=== Brief Medical History ===
_____
* '''Do you take any medications that can cause drowsiness/sleepiness/syncope?''' ❑Yes ❑No
* '''Are you diagnosed with any medical illness that can cause drowsiness/sleepiness/syncope?''' ❑Yes ❑No


'''*How old are you?'''
=== Driving History ===
_____
* '''How do you get to/from work?''' ❑Drive (Car or motorcycle) ❑Public Transportation ❑Bicycle ❑Walk ❑Other - Please specify __________________


===Questions about driving===
*'''How long is your trip to/from work (on average each way)?''' ❑<15 minutes ❑15 to 30 minutes ❑30 to 60 minutes ❑>60 minutes
How do you get to/from work?
❑Drive (Car or motorcycle)
❑Public Transportation
❑Bicycle
❑Walk
❑Other - Please specify __________________


*How long is your trip to/from work? (on average each way)
*'''For how many years have you had a driver's license?''' ❑Less than 5 yrs ❑ 5-10 yrs ❑11-15 yrs ❑16-20 yrs ❑More than 20 yrs
❑<15 minutes
❑15 to 30 minutes
❑30 to 60 minutes
❑>60 minutes


*For how many years are you driving? ❑Less than 5 yrs ❑ 5-10 yrs ❑11-15 yrs ❑16-20 yrs ❑More than 20 yrs
*'''Have you ever been in an accident prior to entering the medical profession?'''
*'''How many motor vehicle accidents have you ever been in?'''
*'''How many of those occurred due to sleeping at the wheel?'''
*'''How many accidents do you attribute to sleep deprivation?'''


*Have you ever been in a "near accident"?
=== Motor Vehicle Accident History ===
* '''Have you ever felt drowsy/fatigued after a work shift?''' ❑Yes ❑No
* '''Have you ever fallen asleep at the wheel after a shift?''' ❑Yes ❑No
* '''Have you ever had a "near accident" while driving after the shift?''' ❑Yes ❑No


*Have you ever been in an accident after your shift?
* '''Have you ever had an accident while driving after the shift?''' ❑Yes ❑No
* '''Do you know any health care professionals who have had a motor vehicle accident after a shift?'''


*How many hours do you sleep?
=== Questions for those with Sleep Deprivation-related Motor Vehicle Accidents ===
What healthcare role do you have in the hospital setting?
* '''How long was your shift immediately prior to the accident? ______'''
*'''How many hours did you work the week of the accident?_____'''
*'''How many hours did you work the month prior to the accident?_____'''


* '''Did your sleep deprivation-related motor vehicle accident result in a visit to the ER?'''❑Yes ❑No
* D'''id your sleep deprivation-related motor vehicle accident result in hospitalization?'''❑Yes ❑No
* '''Did your sleep deprivation-related motor vehicle accident result in admission to an intensive care unit?'''❑Yes ❑No
* '''Did your sleep deprivation-related motor vehicle accident result in life-threatening injuries?'''❑Yes ❑No
* '''Did your sleep deprivation-related motor vehicle accident result in injuries to others?'''❑Yes ❑No
* '''Did your sleep deprivation-related motor vehicle accident result in a visit to the ER for another person?'''❑Yes ❑No
* '''Did your sleep deprivation-related motor vehicle accident result in hospitalization for another person?'''❑Yes ❑No
* '''Did your sleep deprivation-related motor vehicle accident result in admission to an intensive care unit for another person?'''❑Yes ❑No
* '''Did your sleep deprivation-related motor vehicle accident result in life-threatening injuries for another person?'''❑Yes ❑No
* '''Did your sleep deprivation-related motor vehicle accident result in any chronic,permanent or irreversible personal injury?'''❑Yes ❑No
* '''Did you receive any government disability compensation due to this accident?''' ❑Yes ❑No
** '''If so, what was the estimated amount? ________________________'''  ❑Do not know/Do not wish to disclose
* '''Did your sleep deprivation-related motor vehicle accident result in any chronic,permanent or irreversible injury to others?'''❑Yes ❑No
* '''Did any persons involved in the accident receive any government disability compensation as a result of the accident?''' ❑Yes ❑No
** '''If so, what was the estimated amount? ________________________'''  ❑Do not know/Do not wish to disclose


* '''Did the accident cause any psychological disturbance to you or your family members?''' ❑Yes ❑No
** If so, Please specify ❑Acute stress disorder ❑Post traumatic stress disorder ❑Anxiety ❑Depression ❑Phobia


How many hours per week do you currently work (on average)? ______
*
 
What is the duration of your longest shift in the past week (in hours)? ______
What is the duration of your longest shift in the past month (in hours)? ______
What is the duration of your longest shift in the past year (in hours)? ______
 
===Feeling before a shift===
===Feeling after a shift====
Have you ever felt drowsy/fatigued after the shift?
❑Yes
❑No
 
Have you ever felt drowsy while driving after the shift?
❑Yes
❑No
 
Have you ever had an accident while driving after the shift?
❑Yes
❑No
 
How long was the shift after which you had an accident/near accident/drowsiness while driving?
 
What was the extent of damage to you in that accident?
❑Minor
❑Moderate
❑Severe
 
What was the extent of damage to the health of other persons involved in the accident?
❑Minor
❑Moderate
❑Severe
 
What was the extent of damage to the vehicle you were driving?
❑Minor
❑Moderate
❑Severe
 
What was the extent of damage to other vehicles involved in the accident?
❑Minor
❑Moderate
❑Severe
 
What was the extent of damage to the property involved in the accident?
❑Minor
❑Moderate
❑Severe
 
Do you take any medications that can cause drowsiness/sleepiness/syncope?
❑Yes
❑No
 
Are you diagnosed with any medical illness that can cause drowsiness/sleepiness/syncope?
❑Yes
❑No
 
Did you suffer any disability as a result of the accident?
❑Yes
❑No
 
Did the accident cause any psychiatric condition to you or your family members?
❑Yes
❑No
 
Please specify
❑Acute stress disorder
❑Post traumatic stress disorder
❑Anxiety
❑Depression
❑Phobia

Latest revision as of 20:38, 4 August 2017

Questions

General

  • What kind of health care professional are you? ❑Physician ❑Registered Nurse ❑Advanced Practice Nurse ❑Other - Please specify __________________
  • What is your area of specialty? ❑Internal Medicine ❑Pediatrics ❑Surgery ❑Urology ❑Obstetrics & Gynecology ❑Radiology ❑Anesthesia ❑Family Medicine ❑Ophthalmology
  • What is your level of training? (Physicians) ❑Student ❑Intern ❑Resident ❑Fellow ❑Attending
  • How old are you (years)?❑<25 ❑25 to 30 ❑30 to 35 ❑35 to 40 ❑40 to 45❑45 to 50 ❑50 to 55 ❑55 to 60 ❑>60
  • Gender? ❑Male ❑Female ❑Do not wish to disclose

Work Hours

  • How many hours do you work per week? _____
  • What is the duration of your longest shift in the past week (in hours)? ______
  • What is the duration of your longest shift in the past month (in hours)? ______
  • What is the duration of your longest shift in the past year (in hours)? ______

Sleep Habits

  • How many hours do you currently sleep per day (on average)? _____
  • How many hours did you sleep per day before entering the medical profession? _____

Brief Medical History

  • Do you take any medications that can cause drowsiness/sleepiness/syncope? ❑Yes ❑No
  • Are you diagnosed with any medical illness that can cause drowsiness/sleepiness/syncope? ❑Yes ❑No

Driving History

  • How do you get to/from work? ❑Drive (Car or motorcycle) ❑Public Transportation ❑Bicycle ❑Walk ❑Other - Please specify __________________
  • How long is your trip to/from work (on average each way)? ❑<15 minutes ❑15 to 30 minutes ❑30 to 60 minutes ❑>60 minutes
  • For how many years have you had a driver's license? ❑Less than 5 yrs ❑ 5-10 yrs ❑11-15 yrs ❑16-20 yrs ❑More than 20 yrs
  • Have you ever been in an accident prior to entering the medical profession?
  • How many motor vehicle accidents have you ever been in?
  • How many of those occurred due to sleeping at the wheel?
  • How many accidents do you attribute to sleep deprivation?

Motor Vehicle Accident History

  • Have you ever felt drowsy/fatigued after a work shift? ❑Yes ❑No
  • Have you ever fallen asleep at the wheel after a shift? ❑Yes ❑No
  • Have you ever had a "near accident" while driving after the shift? ❑Yes ❑No
  • Have you ever had an accident while driving after the shift? ❑Yes ❑No
  • Do you know any health care professionals who have had a motor vehicle accident after a shift?

Questions for those with Sleep Deprivation-related Motor Vehicle Accidents

  • How long was your shift immediately prior to the accident? ______
  • How many hours did you work the week of the accident?_____
  • How many hours did you work the month prior to the accident?_____
  • Did your sleep deprivation-related motor vehicle accident result in a visit to the ER?❑Yes ❑No
  • Did your sleep deprivation-related motor vehicle accident result in hospitalization?❑Yes ❑No
  • Did your sleep deprivation-related motor vehicle accident result in admission to an intensive care unit?❑Yes ❑No
  • Did your sleep deprivation-related motor vehicle accident result in life-threatening injuries?❑Yes ❑No
  • Did your sleep deprivation-related motor vehicle accident result in injuries to others?❑Yes ❑No
  • Did your sleep deprivation-related motor vehicle accident result in a visit to the ER for another person?❑Yes ❑No
  • Did your sleep deprivation-related motor vehicle accident result in hospitalization for another person?❑Yes ❑No
  • Did your sleep deprivation-related motor vehicle accident result in admission to an intensive care unit for another person?❑Yes ❑No
  • Did your sleep deprivation-related motor vehicle accident result in life-threatening injuries for another person?❑Yes ❑No
  • Did your sleep deprivation-related motor vehicle accident result in any chronic,permanent or irreversible personal injury?❑Yes ❑No
  • Did you receive any government disability compensation due to this accident? ❑Yes ❑No
    • If so, what was the estimated amount? ________________________ ❑Do not know/Do not wish to disclose
  • Did your sleep deprivation-related motor vehicle accident result in any chronic,permanent or irreversible injury to others?❑Yes ❑No
  • Did any persons involved in the accident receive any government disability compensation as a result of the accident? ❑Yes ❑No
    • If so, what was the estimated amount? ________________________ ❑Do not know/Do not wish to disclose
  • Did the accident cause any psychological disturbance to you or your family members? ❑Yes ❑No
    • If so, Please specify ❑Acute stress disorder ❑Post traumatic stress disorder ❑Anxiety ❑Depression ❑Phobia
Retrieved from "https://www.wikidoc.org/index.php?title=Sandbox:survey&oldid=1335917"