Sandbox:survey2

Questions

General

• What is your occupation? -Please specify______________
• How old are you? ❑<25 ❑25-30 ❑31-35 ❑36-40 ❑41-45 ❑46-50 ❑51-55 ❑56-60 ❑>60
• Gender? ❑Male ❑Female ❑Do not wish to disclose

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? -Please specify_______