Sleep deprivation survey (Non-healthcare Workers)

Sleep deprivation survey (Non-healthcare Workers
General Questions
Work and Sleep Hours
Brief Medical History
Epworth Sleepiness Scale
Driving History
Motor Vehicle Accident History
Motor Vehicle Accident History
Questions for those with Sleep Deprivation-related Motor Vehicle Accidents
Employer Policies

Opening Question

• Are you a healthcare worker or a caregiver? ❑ 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 country do you live in? ________________
  • If 'United States', what state do you live in?____________
• 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 many 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)? ______
• What is the duration of your longest shift you have ever worked (in hours)? ______
• How many hours do you currently sleep per day (on average)? _____
• What is the longest duration you have gone without sleep for work-related reasons? _____

Brief Medical History

• Do you take any medications that can cause drowsiness/sleepiness/syncope? ❑ Yes ❑ No
• Have you ever been diagnosed with any medical illness that can cause drowsiness/sleepiness/syncope? ❑ Yes ❑ No
• Does your vision require correction (glasses or contact lenses)? ❑ Yes ❑ No
• Do you have trouble seeing at night? (poor night vision) ❑ 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 theater 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 would you describe the region through which you commute? ❑ Urban ❑ Suburban ❑ Rural
• 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
• 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)

❑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)

❑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)

❑0 ❑1 ❑2 ❑3 ❑4 ❑5 ❑6 ❑7 ❑8 ❑9 ❑10

• Have you ever had an accident while driving after work? ❑ Yes ❑ No

Questions for those with Sleep Deprivation-related Motor Vehicle Accidents

• What time of day did your accident occur? ❑ Daytime ❑ Nighttime
• Did your accident occur on: ❑ City road ❑ Highway
• How would you describe the area where the accident occurred? ❑ Urban ❑ Suburban ❑ Rural
• If you require vision correction, were you wearing your glasses or contact lenses at the time of the accident? ❑ Yes ❑ No ❑ I do not require vision correction
• How long was your shift immediately prior to the accident ? ______
• How long was your shift one day prior to the accident ? ______
• How long was your shift two days prior to the accident? ______
• How long was your shift three days prior to the accident? ______
• How many hours did you work (per day) on the week of the accident (on average per shift)?_____
• How many night shifts did you work on the week of the accident? ______
• How many hours did you work (per day) on the month prior to the accident (on average per shift)?_____
• Did your sleep deprivation-related motor vehicle accident result in a visit to the ER? ❑ Yes ❑ No
• Did your sleep deprivation-related motor vehicle accident result in hospitalization? ❑ Yes ❑ No
• Did your sleep deprivation-related motor vehicle accident result in admission to an intensive care unit? ❑ Yes ❑ No
• Did your sleep deprivation-related motor vehicle accident result in life-threatening injuries? ❑ Yes ❑ No
• Did your sleep deprivation-related motor vehicle accident result in injuries to others? ❑ Yes ❑ No
• Did your sleep deprivation-related motor vehicle accident result in a visit to the ER for another person? ❑ Yes ❑ No
• Did your sleep deprivation-related motor vehicle accident result in hospitalization for another person? ❑ Yes ❑ No
• Did your sleep deprivation-related motor vehicle accident result in admission to an intensive care unit for another person? ❑ Yes ❑ No
• Did your sleep deprivation-related motor vehicle accident result in life-threatening injuries for another person? ❑Yes ❑No
• Did your sleep deprivation-related motor vehicle accident result in any chronic,permanent or irreversible personal injury? ❑ Yes ❑ No
• Did you receive any government disability compensation due to this accident? ❑ Yes ❑ No
  • If so, what was the estimated amount? ________________________ ❑ Do not know/Do not wish to disclose
• Did your sleep deprivation-related motor vehicle accident result in any chronic,permanent or irreversible injury to others? ❑ Yes ❑ No
• Did any persons involved in the accident receive any government disability compensation as a result of the accident? ❑ Yes ❑ No
  • If so, what was the estimated amount? ________________________ ❑ Do not know/Do not wish to disclose
• Did the accident cause any psychological disturbance to you or your family members? ❑ Yes ❑ No
  • If so, Please specify: ❑ Acute stress disorder ❑ Post traumatic stress disorder ❑ Anxiety ❑ Depression ❑ Phobia

Employer Policies

• Does your employer have preventative policies, programs, or benefits in place to protect its staff from driving while sleep deprived? ❑ Yes ❑ No ❑ Do not know
• Do you feel these preventative measures are sufficient? ❑ Yes ❑ No

Future Studies

• Would you be willing to participate in a prospective study involving a brief questionnaire before and after your work shift? ❑ Yes ❑ No ❑ Maybe
  

If 'Yes' or 'Maybe', continue:

• How long do you think a reasonable daily survey on work-related fatigue and sleep deprivation should take to complete? (in minutes) _______
• What type of survey would appeal to you most ❑ Paper-based (sent by mail) ❑ Paper-based (sent by email and printed by you) ❑ Phone application ❑ Survey link sent by email ❑ Survey link sent by text message
• Would you be interested in being contacted with more information if such a study is initiated? ❑ Yes ❑ No