Sleep Deprivation Survey (Healthcare Workers)

General Questions

Work Hours

Sleep Habits

Brief Medical History

Epworth Sleepiness Scale

Driving History

Motor Vehicle Accident History

Motor Vehicle Accident History

Questions for those with Sleep Deprivation-related Motor Vehicle Accidents

Questions for those who know Someone who Experienced Sleep Deprivation-related Motor Vehicle Accidents

Institutional Policies

## Opening Question

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* 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)

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### General

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* How old are you (years)?______ ❑ Do not wish to disclose
* Gender? ❑ Male ❑ Female ❑ Do not wish to disclose

* What country do you live in? ________________

*     * If 'United States', what state do you live in?____________

* 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
* Are you a caregiver to elderly, ill, physically disabled, or mentally disabled individuals? (paid or unpaid) ❑ Yes ❑ No

### Work Hours

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* How many hours do you work per week? (on average) _____
* How many days do you work per week? (on average) _____
* Do you work during the: ❑ Daytime ❑ Nighttime ❑ Both
* If you answered 'Both', how days a week do you work at nighttime? ______
* If you answered 'Both', how many days per week do you work during the day? _____
* 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)? ______
* What is the duration of your longest shift you have ever worked (in hours)? ______

### Sleep Habits

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* How many hours do you currently sleep per day (on average)? _____
* How many hours did you sleep per day before entering the medical profession? _____
* What is the longest duration you have gone without sleep for work-related reasons? _____

### Brief Medical History

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* 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
* Does your vision require correction (glasses or contact lenses)? ❑ Yes ❑ No
* Do you have trouble seeing at night? (poor night vision) ❑ Yes ❑ No

### Epworth Sleepiness Scale

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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: ❑0 ❑1 ❑2 ❑3
* Sitting, inactive in a public place (e.g. a theater 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

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* How do you get to/from work? ❑ Drive (Car or motorcycle) ❑ Public Transportation ❑ Bicycle ❑ Walk ❑ Other - Please specify __________________
* How would you describe the region through which you commute? ❑ Urban ❑ Suburban ❑ Rural
* 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 or impaired driving due to lack of sleep while at the wheel? _______
* How many of those accidents do you attribute to sleep deprivation? _______

### Motor Vehicle Accident History

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* Have you ever felt drowsy/fatigued while driving 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

### Questions for those with Sleep Deprivation-related Motor Vehicle Accidents

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* What time of day did your accident occur? ❑ Daytime ❑ Nighttime
* Did your accident occur on: ❑ City road ❑ Highway
* How would you describe the area where the accident occurred? ❑ Urban ❑ Suburban ❑ Rural
* If you require vision correction, were you wearing your glasses or contact lenses at the time of the accident? ❑ Yes ❑ No ❑ I do not require vision correction
* How long was your shift immediately prior to the accident (on average)? ______
* How long was your shift one day prior to the accident (on average)? ______
* How long was your shift two days prior to the accident (on average)? ______
* How long was your shift three days prior to the accident (on average)? ______
* How many hours did you work (per day) on the week of the accident (on average per shift)?_____
* How many night shifts did you work on the week of the accident? ______
* How many hours did you work (per day) 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

### Questions for those who know Someone who Experienced Sleep Deprivation-related Motor Vehicle Accidents

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* What time of day did your accident occur? ❑ Daytime ❑ Nighttime ❑ Do not know
* Did this accident occur on: ❑ City road ❑ Highway ❑ Do not know
* How would you describe the area where the accident occurred? ❑ Urban ❑ Suburban ❑ Rural ❑ Do not know
* If this person requires vision correction, were they wearing their glasses or contact lenses at the time of the accident? ❑ Yes ❑ No ❑ He/She does not require vision correction ❑ I Do not know
* How long was this person's shift immediately prior to the accident (on average)? ______ ❑ Do not know
* How long was this person's shift one day prior to the accident (on average)? ______ ❑ Do not know
* How long was this person's shift two days prior to the accident (on average)? ______ ❑ Do not know
* How long was this person's shift three days prior to the accident (on average)? ______ ❑ Do not know
* How many hours did this person work (per day) on the week of the accident (on average per shift)?_____ ❑ Do not know
* How many night shifts did this person work on the week of the accident? ______ ❑ Do not know
* How many hours did this person work (per day) on 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

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* If you experienced a sleep deprivation-related motor vehicle accident, did you report it your institution? ❑ Yes ❑ No
* 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

### Future Studies

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* Would you be willing to participate in a prospective study involving a brief questionnaire before and after your work shift? ❑ Yes ❑ No ❑ Maybe

If 'Yes' or 'Maybe', continue:

* How long do you think a reasonable daily survey on work-related fatigue and sleep deprivation should take to complete? (in minutes)  _______
* What type of survey would appeal to you most  ❑ Paper-based (sent by mail) ❑ Paper-based (sent by email and printed by you) ❑ Phone application ❑ Survey link sent by email ❑ Survey link sent by text message
* Would you be interested in being contacted with more information if such a study is initiated? ❑ Yes ❑ No

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