Sleep deprivation survey (Healthcare Workers)

# Opening Question
- Are you a healthcare worker?  Yes  No
(If 'Yes', continue on this page. If 'No', click here for the non-healthcare professionals survey)

# Sleep Deprivation Survey (for Healthcare Workers)

## General
- How old are you (years)?______  Do not wish to disclose
- Gender?  Male  Female  Do not wish to disclose
- What country do you live in? ________________
- If 'United States', what state do you live in?____________
- If 'United States', what state do you live in?____________
- What kind of health care professional are you?  Physician  Registered Nurse  Physician Assistant  Advanced Practice Nurse  Other - Please specify __________________
- What is your area of specialty?  Internal Medicine  Pediatrics  Surgery  Urology  Obstetrics & Gynecology  Radiology  Anesthesia  Family Medicine  Ophthalmology  Other - Please specify __________________
- What is your level of training? (Physicians)  Student  Intern  Resident  Fellow  Attending
- Are you a caregiver to elderly, ill, physically disabled, or mentally disabled individuals? (paid or unpaid)   Yes  No

## Work 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 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)? ______
- What is the duration of your longest shift you have ever worked (in hours)? ______

## Sleep Habits
- How many hours do you currently sleep per day (on average)? _____
- How many hours did you sleep per day before entering the medical profession? _____
- 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
- Are you 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)?  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 or impaired driving due to lack of sleep while 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 a work shift?  Yes  No
- Have you ever fallen asleep at the wheel after a shift?  Yes  No
- Have you ever had a "near accident" while driving after the shift?  Yes  No
- Have you ever had an accident while driving after the shift?  Yes  No
- Do you know any health care professionals who have had a motor vehicle accident after a shift?  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 (on average)? ______
- How long was your shift one day prior to the accident (on average)? ______
- How long was your shift two days prior to the accident (on average)? ______
- How long was your shift three days prior to the accident (on average)? ______
- 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
- 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
- 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
- If so, Please specify:  Acute stress disorder  Post traumatic stress disorder  Anxiety  Depression  Phobia

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

## Institutional Policies
- If you experienced a sleep deprivation-related motor vehicle accident, did you report it your institution?  Yes  No
- Does your institution 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