Sleep deprivation survey (Non-healthcare Workers)
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Sleep deprivation survey (Non-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 Non-healthcare Workers)
General
- What is your occupation? -Please specify______________
- How old are you? ❑<25 ❑25-30 ❑31-35 ❑36-40 ❑41-45 ❑46-50 ❑51-55 ❑56-60 ❑>60
- Gender? ❑Male ❑Female ❑Do not wish to disclose
Work time and duration
- How many hours a day do you work?
Epworth Sleepiness Scale
- How likely are you to doze-off in the following situations:
(0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing)
- 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
Sleepiness
- Are you diagnosed with a sleeping disorder? ❑Yes ❑No
- How likely are you to doze-off in the following situations:
(0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing)
- 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
- What was your total score: ❑0-10 ❑10-12 ❑12-24
- How many near-miss accidents have you had during the past one month? ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6
- How many times did you feel sleepy while driving during the past one month? ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6
- At what time of the day did the sleepiness occur the most while driving?❑5am-10am ❑10am-3pm ❑3pm-8pm ❑8pm-12am ❑12am-5am
- In the past one month, how many times did you have to stop your car because of sleepiness while driving? ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6
- What was the primary cause of drowsiness during the past one month? ❑Sleep deprivation ❑Medications ❑Sleep disorder ❑Other
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