Sleep deprivation survey (Non-healthcare Workers)

Sleep deprivation survey (Non-healthcare Workers
General Questions
Work and Sleep Hours
Brief Medical History
Epworth Sleepiness Scale
Driving History
Motor Vehicle Accident History
Motor Vehicle Accident History
Questions for those with Sleep Deprivation-related Motor Vehicle Accidents
Employer Policies

Opening Question

• Are you a healthcare worker? ❑ Yes ❑ No

(If 'No', continue on this page. If 'Yes', click here for the Healthcare professionals survey)

Sleep Deprivation Survey (For Non-healthcare Workers)

General

• How old are you (years)?______ ❑ Do not wish to disclose
• Gender? ❑Male ❑Female ❑Do not wish to disclose
• What is your occupation? _________________

Work and Sleep Hours

• How many hours do you work per week? (on average) _____
• How many days do you work per week? (on average) _____
• Do you work during the: ❑ Daytime ❑ Nighttime ❑ Both
• If you answered 'Both', how days a week do you work at nighttime? ______
• If you answered 'Both', how many days per week do you work during the day? _____
• What is the longest duration you worked (per day) in the past week (in hours)? ______
• 'What is the longest duration you worked (per day) in the past' month (in hours)? ______
• 'What is the longest duration you worked (per day) in the past' year (in hours)? ______
• How many hours do you currently sleep per day (on average)? _____

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

Epworth Sleepiness Scale

How likely are you to doze-off in the following situations:

(0 = Would never doze-off; 1 = Slight chance of dozing-off; 2= Moderate chance of dozing-off; 3 = High chance of dozing-off)

• Watching TV: ❑0 ❑1 ❑2 ❑3
• Sitting and reading: ❑0 ❑1 ❑2 ❑3
• Sitting, inactive in a public place (e.g. a theatre or a meeting): ❑0 ❑1 ❑2 ❑3
• As a passenger in a car for an hour without a break: ❑0 ❑1 ❑2 ❑3
• Lying down to rest in the afternoon when circumstances permit: ❑0 ❑1 ❑2 ❑3
• Sitting and talking to someone: ❑0 ❑1 ❑2 ❑3
• Sitting quietly after a lunch without alcohol: ❑0 ❑1 ❑2 ❑3
• In a car, while stopped for a few minutes in the traffic: ❑0 ❑1 ❑2 ❑3

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? ❑ Yes ❑ No

• How many motor vehicle accidents have you ever been in? _______
• How many of those occurred due to sleeping at the wheel? _______
• How many of those 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? ❑ Yes ❑ No

EXTRA

• How many near-miss accidents have you had during the past one month? ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6
• How many times did you feel sleepy while driving during the past one month? ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6
• At what time of the day did the sleepiness occur the most while driving?❑5am-10am ❑10am-3pm ❑3pm-8pm ❑8pm-12am ❑12am-5am
• In the past one month, how many times did you have to stop your car because of sleepiness while driving? ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6
• What was the primary cause of drowsiness during the past one month? ❑Sleep deprivation ❑Medications ❑Sleep disorder ❑Other