Sandbox:survey

# Questions

## General
- What kind of health care professional are you? Physician Registered Nurse Advanced Practice Nurse Other - Please specify __________________
- What is your area of specialty? Internal Medicine Pediatrics Surgery Urology Obstetrics & Gynecology Radiology Anesthesia Family Medicine Ophthalmology
- What is your level of training? (Physicians) Student Intern Resident Fellow Attending
- How old are you (years)?60
- Gender? Male Female Do not wish to disclose

## Work Hours
- How many hours do you work per week? _____
- 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)? ______

## 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? _____

## 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

## 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)? 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?
- How many motor vehicle accidents have you ever been in?
- How many of those occurred due to sleeping at the wheel?
- How many accidents do you attribute to sleep deprivation?

## Motor Vehicle Accident History
- Have you ever felt drowsy/fatigued 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?

## Questions for those with Sleep Deprivation-related Motor Vehicle Accidents
- How long was your shift immediately prior to the accident? ______
- How many hours did you work the week of the accident?_____
- How many hours did you work the month prior to the accident?_____
- 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