Sleep deprivation survey (Healthcare Workers)

Sleep Deprivation Survey (Healthcare Workers)
General Questions
Work Hours
Sleep Habits
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
Questions for those who know Someone who Experienced Sleep Deprivation-related Motor Vehicle Accidents
Institutional Policies

Sleep Deprivation Survey

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

Questions for those who know people who Experienced Sleep Deprivation-related Motor Vehicle Accidents

• How long was the persons' shift immediately prior to the accident? ______ ❑ Do not know
• How many hours did this person work the week of the accident?_____ ❑ Do not know
• How many hours did this person work the month prior to the accident?_____ ❑ Do not know
• Did this persons' sleep deprivation-related motor vehicle accident result in a visit to the ER?❑ Yes ❑ No ❑ Do not know
• Did this persons'sleep deprivation-related motor vehicle accident result in hospitalization?❑ Yes ❑ No ❑ Do not know
• Did this persons' sleep deprivation-related motor vehicle accident result in admission to an intensive care unit?❑Y es ❑ No ❑ Do not know
• Did this persons' sleep deprivation-related motor vehicle accident result in life-threatening injuries?❑ Yes ❑ No ❑ Do not know
• Did this persons' sleep deprivation-related motor vehicle accident result in injuries to others?❑ Yes ❑ No ❑ Do not know
• Did this persons' sleep deprivation-related motor vehicle accident result in a visit to the ER for another person?❑ Yes ❑ No ❑ Do not know
• Did this persons' deprivation-related motor vehicle accident result in hospitalization for another person?❑ Yes ❑ No ❑ Do not know
• Did this persons' sleep deprivation-related motor vehicle accident result in admission to an intensive care unit for another person? ❑ Yes ❑ No ❑ Do not know
• Did this persons' sleep deprivation-related motor vehicle accident result in life-threatening injuries for another person?❑ Yes ❑ No ❑ Do not know
• Did this persons' sleep deprivation-related motor vehicle accident result in any chronic,permanent or irreversible personal injury?❑Yes ❑ No ❑ Do not know
• Did this person receive any government disability compensation due to this accident? ❑ Yes ❑ No ❑ Do not know
  • If so, what was the estimated amount? ________________________ ❑ Do not know/Do not wish to disclose
• Did this persons sleep deprivation-related motor vehicle accident result in any chronic,permanent or irreversible injury to others?❑Yes ❑ No ❑ Do not know
• Did any persons involved in the accident receive any government disability compensation as a result of the accident? ❑ Yes ❑ No ❑ Do not know
  • 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 ❑ Do not know
  • If so, Please specify: ❑ Acute stress disorder ❑ Post traumatic stress disorder ❑ Anxiety ❑ Depression ❑ Phobia