Sandbox:survey

Questions

General Questions

*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 many hours do you work per week?' _____

*How old are you? _____

Questions about driving

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 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 a "near accident"?

• Have you ever been in an accident after your shift?

• How many hours do you sleep?

What healthcare role do you have in the hospital setting?

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 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