Sleep deprivation survey (Healthcare Workers)

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Sleep Deprivation Survey

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)?❑<25 ❑25 to 30 ❑30 to 35 ❑35 to 40 ❑40 to 45❑45 to 50 ❑50 to 55 ❑55 to 60 ❑>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)? ❑<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?
  • 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
  • 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
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