View source for Sleep deprivation survey (Healthcare Workers)

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{{Sleep Deprivation Survey}}
==Sleep Deprivation Survey==
===General===
* '''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
* '''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 ❑ Do not wish to disclose
* '''Gender?''' ❑ Male ❑ Female ❑ Do not wish to disclose

=== Work Hours ===
* '''How many hours do you work per week? (on average)''' _____
* '''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
* D'''id 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

=== Questions for those who know people who Experienced Sleep Deprivation-related Motor Vehicle Accidents ===
* '''How long was the persons' shift immediately prior to the accident?''' ______  ❑ Do not know
*'''How many hours did '''this person''' work the week of the accident?'''_____  ❑ Do not know
*'''How many hours did '''this person''' work the month prior to the accident?'''_____  ❑ 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
* '''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 
* '''Did the accident cause any psychological disturbance to you or your family members?''' ❑ Yes ❑ No ❑ Do not know
** '''If so, Please specify:''' ❑ Acute stress disorder ❑ Post traumatic stress disorder ❑ Anxiety ❑ Depression ❑ Phobia 

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