Sleep deprivation survey (Non-healthcare Workers)
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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
- How old are you (years)?______ ❑ Do not wish to disclose
- Gender? ❑Male ❑Female ❑Do not wish to disclose
- What is your occupation? _________________
- What industry do you work in?
- ❑ Advertising ❑ Agriculture ❑ Arts/Entertainment ❑ Custodial ❑ Distribution/Delivery ❑ Education ❑ Finance/Accounting/Banking ❑Food/Restaurant ❑ Government employee ❑ Health
❑ Information Technology/Software ❑ Insurance ❑ Law/Legal services ❑ Management ❑ Production/Manufacturing ❑ Publishing ❑Real Estate ❑ Research ❑ Sales/Marketing ❑ Television ❑ Trades ❑ Transportation ❑ Other: __________________(Please specify)
- Please select the option that best describes your job setting: (select all that apply)
- ❑ Office ❑ Construction/Work-site ❑Client/Customer-site (home or office) ❑ Work-from-home ❑ Vehicle ❑ Factory/Warehouse ❑ Retail/Grocery store ❑ Other: _________________(Please specify)
- On a scale of 0 to 10, what proportion of your work day is spent on your feet?
(0 = I am never on my feet at work & 10 = I am on my feet the entire time at work)
- ❑0 ❑1 ❑2 ❑3 ❑4 ❑5 ❑6 ❑7 ❑8 ❑9 ❑10
- Is driving your primary duty at work? ❑ Yes ❑ No
- Does your job require travel (NOT the commute to/from work)? ❑ Yes ❑ No
- If so, What kind of travel? ❑ Air ❑ Motor Vehicle ❑ Public transit ❑ Bicycle
- What percentage of your work day involves travel? _________
- How would you describe the proximity of most of your work-related travel? ❑ Local ❑ Out-of-city/town ❑ Out-of-state ❑ International
Work and Sleep Hours
- How many hours do you work per week? (on average) _____
- How many days do you work per week? (on average) _____
- Do you work during the: ❑ Daytime ❑ Nighttime ❑ Both
- If you answered 'Both', how days a week do you work at nighttime? ______
- If you answered 'Both', how many days per week do you work during the day? _____
- What is the longest duration you worked (per day) in the past week (in hours)? ______
- 'What is the longest duration you worked (per day) in the past' month (in hours)? ______
- 'What is the longest duration you worked (per day) in the past' year (in hours)? ______
- How many hours do you currently sleep per day (on average)? _____
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 while driving after work? ❑ Yes ❑ No
- On a scale of 0 to 10, how often does this happen?
(0 = Never & 10 = Always)
- On a scale of 0 to 10, how often does this happen?
- ❑0 ❑1 ❑2 ❑3 ❑4 ❑5 ❑6 ❑7 ❑8 ❑9 ❑10
- ❑0 ❑1 ❑2 ❑3 ❑4 ❑5 ❑6 ❑7 ❑8 ❑9 ❑10
- Have you ever fallen asleep at the wheel after work? ❑ Yes ❑ No
- On a scale of 0 to 10, how often does this happen?
(0 = Never & 10 = Always)
- On a scale of 0 to 10, how often does this happen?
- ❑0 ❑1 ❑2 ❑3 ❑4 ❑5 ❑6 ❑7 ❑8 ❑9 ❑10
- Have you ever had a "near accident" while driving after work? ❑ Yes ❑ No
- On a scale of 0 to 10, how often does this happen?
(0 = Never & 10 = Always)
- On a scale of 0 to 10, how often does this happen?
- ❑0 ❑1 ❑2 ❑3 ❑4 ❑5 ❑6 ❑7 ❑8 ❑9 ❑10
- Have you ever had an accident while driving after work? ❑ 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