Sleep deprivation survey (Non-healthcare Workers): Difference between revisions
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* '''Gender?''' ❑Male ❑Female ❑Do not wish to disclose | * '''Gender?''' ❑Male ❑Female ❑Do not wish to disclose | ||
===Work | === Work Hours === | ||
* '''How many hours | * '''How many hours do you work per week? (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)? ______''' | |||
=== '''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 | |||
===Epworth Sleepiness Scale=== | ===Epworth Sleepiness Scale=== | ||
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* '''Watching TV:''' ❑0 ❑1 ❑2 ❑3 | * '''Watching TV:''' ❑0 ❑1 ❑2 ❑3 | ||
* '''Sitting and reading:''' ❑0 ❑1 ❑2 ❑3 | * '''Sitting and reading:''' ❑0 ❑1 ❑2 ❑3 | ||
* '''Sitting, inactive in a public place (e.g. a | * '''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 | * '''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 | * '''Lying down to rest in the afternoon when circumstances permit:''' ❑0 ❑1 ❑2 ❑3 | ||
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* '''In a car, while stopped for a few minutes in the traffic:''' ❑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 | |||
*'''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 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 | * '''How many times did you feel sleepy while driving during the past one month?''' ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6 | ||
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* '''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 | * '''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 | * '''What was the primary cause of drowsiness during the past one month?''' ❑Sleep deprivation ❑Medications ❑Sleep disorder ❑Other | ||
Revision as of 15:29, 8 August 2017
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Sleep deprivation survey (Non-healthcare Workers |
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Questions for those with Sleep Deprivation-related Motor Vehicle Accidents |
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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 Hours
- How many hours do you work per week? (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)? ______
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
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