Sandbox:survey
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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 before a shift
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