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

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

Work time and duration

• How many hours a day do you work?

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 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

Sleepiness

• Are you diagnosed with a sleeping disorder? ❑Yes ❑No
• How likely are you to doze-off in the following situations:

(0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing)

• • Watching TV: ❑0 ❑1 ❑2 ❑3
  • Sitting and reading 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
  • What was your total score: ❑0-10 ❑10-12 ❑12-24
• 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

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