Sleep deprivation survey (Non-healthcare Workers)

# 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?____________
- If 'United States', what state do you live in?____________
- What industry do you work in?
- Please select the option that best describes your job setting: (select all that apply)
- 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)
- 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)?  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)
- On a scale of 0 to 10, how often does this happen?(0 = Never & 10 = Always)
- 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 = Never & 10 = Always)
- 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 = Never & 10 = Always)
- 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
- 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

## 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