Sleep deprivation survey (Healthcare Workers)
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Sleep Deprivation Survey (Healthcare Workers) |
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Questions for those with Sleep Deprivation-related Motor Vehicle Accidents |
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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
- 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)?______ ❑ 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
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 Sitting and reading: ❑0 ❑1 ❑2 ❑3
- Sitting, inactive in a public place (e.g. a theatre 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 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? ❑ Yes ❑ No
- 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 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
- How long was your shift immediately prior to the accident (on average)? ______
- How many hours did you work on the week of the accident (on average per shift)?_____
- How many hours did you work 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
- 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
- How long was the persons' shift immediately prior to the accident (on average)? ______ ❑ Do not know
- How many hours did this person work in the week of the accident (on average per shift)?_____ ❑ Do not know
- How many hours did this person work in 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
- 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 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
Institutional Policies
- 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