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107 A p p e n d i x B Sleep Questionnaire
108 Sleep Questionnaire There are 80 questions in this survey SLEEP 1 1 What is your current work status? (Choose all that apply) Please choose all that apply: Full Time employment outside the home Part Time employment outside the home Full Time employment, work from home Part Time employment, work from home Full Time stay at home parent Disabled Unemployed Full Time student Part Time student Other: 2 On days you are working outside of the home, are your sleep habits: Only answer this question if the following conditions are met: ° -------- Scenario 1 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) -------- or Scenario 2 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) Please choose only one of the following: Regular Highly variable 3 On days you are working outside of the home, what time do you usually go to bed? Only answer this question if the following conditions are met: ° -------- Scenario 1 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply))
109 -------- or Scenario 2 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) Please choose only one of the following: Midnight 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM NOON 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM
110 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM 4 On days you are working outside of the home, what time do you usually wake up? Only answer this question if the following conditions are met: ° -------- Scenario 1 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) -------- or Scenario 2 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) Please choose only one of the following: Midnight 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM
111 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM NOON 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM 5 On days you are working from home, are your sleep habits: Only answer this question if the following conditions are met: °
112 -------- Scenario 1 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) -------- or Scenario 2 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) Please choose only one of the following: Regular Highly variable 6 On days you are working from home, what time do you usually go to bed? Only answer this question if the following conditions are met: ° -------- Scenario 1 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) -------- or Scenario 2 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) Please choose only one of the following: Midnight 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM
113 10:00 AM 10:30 AM 11:00 AM 11:30 AM NOON 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM 7 On days you are working from home, what time do you usually wake up? Only answer this question if the following conditions are met: ° -------- Scenario 1 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) -------- or Scenario 2 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) Please choose only one of the following:
114 Midnight 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM NOON 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM
115 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM 8 Do you keep a fairly regular sleep schedule? Please choose only one of the following: Yes No 9 On average, how much sleep do you get in 24 hours on days when you are working? Only answer this question if the following conditions are met: ° -------- Scenario 1 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) -------- or Scenario 2 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) -------- or Scenario 3 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) -------- or Scenario 4 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) -------- or Scenario 5 -------- Answer was at question '1 [1]' (What is your current work status? (Choose all that apply)) Please write your answer(s) here: hours: minutes:
116 10 On average, how much sleep do you get in 24 hours on days when you are not working? Please write your answer(s) here: hours: minutes: 11 How much sleep do you feel you need every 24 hours to feel well rested? Please write your answer(s) here: hours: minutes: 12 How would you characterize yourself as a sleeper? Please choose only one of the following: Light Normal Heavy 13 Do you ever choose to sleep sitting up or in a recliner? Please choose only one of the following: Yes No 14 How often do you nap (any sleep in addition to your major daily sleep period)? Please choose only one of the following: Nearly every day 3-4 times per week 1-2 times per week 3-4 times per month 1-2 times per month
117 Rarely Never 15 On average, how long do your naps last? Only answer this question if the following conditions are met: ° Answer was greater than 'Never' at question '14 [12]' (How often do you nap (any sleep in addition to your major daily sleep period)?) Please write your answer(s) here: hours: minutes: 16 Do you feel uncomfortably sleepy during the day or find that you fall asleep in unusual or inappropriate situations? Please choose only one of the following: Every day More than once per week About once a week A few times a month About once a month Rarely Never 17 In the LAST MONTH, how many times did you nod off or fall asleep Please write your answer(s) here: while stopped in traffic: while driving: 18 In the LAST YEAR, how many times did you nod off or fall asleep Please write your answer(s) here: while stopped in traffic: while driving:
118 19 In the LAST WEEK, on average, how many servings of caffeine did you consume per 24 hour period? Please choose only one of the following: None 1/2 serving per day 1-2 servings per day 3-4 servings per day 5-6 servings per day 7-8 servings per day More than 8 servings per day Count: 12 ounces of cola as 1/2 serving 8 ounces of energy drink as 1 serving 8 ounces of tea as 1/2 serving 8 ounces of home brew coffee as 1 serving 1 shot of espresso as 1 servings 1 Grande Starbucks as 3 servings 1 dose of NoDoz or Vivarin as 2 servings 1 dose of medicine containing caffeine as 1 serving
119 20 In a TYPICAL WEEK, on average, how many servings of caffeine do you consume per 24 hour period? Please choose only one of the following: None 1/2 serving per day 1-2 servings per day 3-4 servings per day 5-6 servings per day 7-8 servings per day More than 8 servings per day Count: 12 ounces of cola as 1/2 serving 8 ounces of energy drink as 1 serving 8 ounces of tea as 1/2 serving 8 ounces of home brew coffee as 1 serving 1 shot of espresso as 1 servings 1 Grande Starbucks as 3 servings 1 dose of NoDoz or Vivarin as 2 servings 1 dose of medicine containing caffeine as 1 serving 21 In the LAST WEEK what is the pattern of your caffeine consumption? Please choose only one of the following: Drink or take it all at once (e.g., at the beginning of the work shift) Drink or take it throughout the day Varies considerably 22 In a TYPICAL WEEK what is the pattern of your caffeine consumption? Please choose only one of the following: Drink or take it all at once (e.g., at the beginning of the work shift) Drink or take it throughout the day Varies considerably 23 In the LAST WEEK how many alcoholic beverages did you consume? Please choose only one of the following: None
120 1-2 servings per week 3-5 servings per week 6-7 servings per week 8-14 servings per week more than 14 servings per week One serving equals: 1 glass, bottle, or can of beer 4 ounces of wine 1 mixed drink or shot of liquor 24 In a TYPICAL WEEK how many alcoholic beverages do you consume? Please choose only one of the following: None 1-2 servings per week 3-5 servings per week 6-7 servings per week 8-14 servings per week more than 14 servings per week One serving equals: 1 glass, bottle, or can of beer 4 ounces of wine 1 mixed drink or shot of liquor 25 Do you use tobacco products (e.g., smoke cigarettes, cigars, or a pipe or chew or snuff tobacco)? Please choose only one of the following: Yes No 26 If "yes", how much or how often (e.g., a pack/day, a pouch/week, etc.)? Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '25 [25]' (Do you use tobacco products (e.g., smoke cigarettes, cigars, or a pipe or chew or snuff tobacco)?) Please write your answer here:
121 27 Have you used any sleep aids in the LAST MONTH? Please choose only one of the following: Yes, regularly Yes, intermittently (i.e. - during times of stress or illness) Yes, rarely No, never 28 How frequently do you use sleep aids in a TYPICAL MONTH? Please choose only one of the following: Regularly use Intermittently use (i.e. - during times of stress or illness) Rarely use Never use 29 Which of the following sleep aids do you use? (Choose all that apply) Please choose all that apply: None, I don't ever use sleep aids. Sleeping Pills, Over the Counter (OTC) Sleep Pills, Prescription Continuous Positive Airway Pressure (CPAP) Machine Nasal opening strips (e.g., Breathe Right®) White background noise (e.g. fan, noise machine, humidifier) Other:
122 30 In the LAST MONTH, what was the number of times that you have been awake in the following categories: Please write your answer(s) here: Awake 30 or more continuous hours: Awake 24 or more continuous hours (but less than 30 hours): Awake 20 or more continuous hours (but less than 24 hours): 31 What is your occupation? Please write your answer here: 32 For approximately how many nights in the PAST YEAR did you work overnight or a "night shift" (any 8-10 hour shift between approximately 10pm and 8am or any 12 hour shift between approximately 7pm and 9am)? Please write your answer here: 33 Do you have children that currently live in your home at least half of the time? Please choose only one of the following: Yes No 34 How many of those children are in the following age groups? (Fill in all that apply) Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '33 [34]' (Do you have children that currently live in your home at least half of the time?) Please write your answer(s) here: 0-2 years: 3-5 years: 6-10 years (elementary school aged): 11-13 years (middle school aged): 14-18 years (high school aged):
123 Over 18 years: 35 In the LAST MONTH, how often have you been awakened in the night by any of your children? Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '33 [34]' (Do you have children that currently live in your home at least half of the time?) Please choose only one of the following: Never Rarely Sometimes Often Every night 36 On nights when you were awakened by your children in the LAST MONTH, how long in total were you awake over the course of the night, on average? Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '33 [34]' (Do you have children that currently live in your home at least half of the time?) and Answer was 'Rarely' or 'Sometimes' or 'Often' or 'Every night' at question '35 [35]' (In the LAST MONTH, how often have you been awakened in the night by any of your children?) Please write your answer(s) here: hours: minutes: 37 On nights when you were awakened by your children in the LAST MONTH, how many times per night, on average, were you awakened? Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '33 [34]' (Do you have children that currently live in your home at least half of the time?) and Answer was 'Rarely' or 'Sometimes' or 'Often' or 'Every night' at question '35 [35]' (In the LAST MONTH, how often have you been awakened in the night by any of your children?) Please choose only one of the following: Once 2-3 times More than 3 times
124 Please use the following definitions as a guide for the questions below: Day shift: occurs anytime between 6am and 7pm Evening shift: occurs anytime between 3 pm and midnight Night shift: is any 8-10 hour shift between approximately 10pm and 8am or any 12 hour shift between approximately 7pm and 9am If your work schedule doesnât exactly fit into one of these categories, please use the shift category that most closely resembles your shift. To your best recollection: Please describe your activity during each week. Note that there are 168 hours in one week (7days x 24 hours) 39 For the PAST WEEK, select all of the activities that apply: Please choose all that apply: Not working Day shift Evening shift Night shift Other, (please specify): 40 For the PAST WEEK: Please write your answer(s) here: Hours spent working (include all time working at your regular job, overtime, second job, etc.): {NOT EMPTY} Hours of sleep (Sum hours of sleep for all seven days of the week) : 41 For the PAST WEEK, indicate the number of days off (include vacation, sick days, and other full days off): Please write your answer here: 38 The following questions ask about your actual work hours in the LAST MONTH.
125 42 For the PAST WEEK, was this week typical for you? Please choose only one of the following: Yes No 43 For the week, the PAST WEEK, why wasn't this week typical for you? Only answer this question if the following conditions are met: ° Answer was 'No' at question '42 [42]' (For the PAST WEEK, was this week typical for you?) Please write your answer here: 44 For the week, TWO WEEKS AGO, select all of the activities that apply: Please choose all that apply: Not working Day shift Evening shift Night shift Other, (please specify): 45 For the week TWO WEEKS AGO: Please write your answer(s) here: Hours spent working (include all time working at your regular job, overtime, second job, etc.): {NOT EMPTY} Hours of sleep (Sum hours of sleep for all seven days of the week) :
126 vacation, sick days, and other full days off); Please write your answer here: 47 For the week, TWO WEEKS AGO, was this week typical for you? Please choose only one of the following: Yes No 48 For the week, TWO WEEKS AGO, why wasn't this week typical for you? Only answer this question if the following conditions are met: ° Answer was 'No' at question '47 [47]' (For the week, TWO WEEKS AGO, was this week typical for you?) Please write your answer here: 49 For the week, THREE WEEKS AGO, select all of the activities that apply: Please choose all that apply: Not working Day shift Evening shift Night shift Other, (please specify): 46 For the week, TWO WEEKS AGO, indicate the number of days off (include
127 Hours spent working (include all time working at your regular job, overtime, second job, etc.): {NOT EMPTY} Hours of sleep (Sum hours of sleep for all seven days of the week) : 51 For the week, THREE WEEKS AGO, indicate the number of days off (include vacation, sick days, and other full days off): Please write your answer here: 52 For the week, THREE WEEKS AGO, was this week typical for you? Please choose only one of the following: Yes No 53 For the week, THREE WEEKS AGO, why wasn't this week typical for you? Only answer this question if the following conditions are met: ° Answer was 'No' at question '52 [52]' (For the week, THREE WEEKS AGO, was this week typical for you?) Please write your answer here: 50 For the week, THREE WEEKS AGO: Please write your answer(s) here:
128 54 For the week, FOUR WEEKS AGO, select all of the activities that apply: Please choose all that apply: Not working Day shift Evening shift Night shift Other, (please specify): 55 For the week FOUR WEEKS AGO: Please write your answer(s) here: Hours spent working (include all time working at your regular job, overtime, second job, etc.): {NOT EMPTY} Hours of sleep (Sum hours of sleep for all seven days of the week) : 56 For the week, FOUR WEEKS AGO, indicate the number of days off (include vacation, sick days, and other full days off): Please write your answer here: 57 For the week, FOUR WEEKS AGO, was this week typical for you? Please choose only one of the following: Yes No 58 For the week, FOUR WEEKS AGO, why wasn't this week typical for you? Only answer this question if the following conditions are met: ° Answer was 'No' at question '57 [57]' (For the week, FOUR WEEKS AGO, was this week typical for you?) Please write your answer here:
129 59 In the LAST MONTH, what was the greatest number of continuous hours you worked? Please write your answer here: (Consider hours continuous even if there was a break of up to 4 hours. Include primary job, mandatory overtime, voluntary overtime, second job, and any additional employment.) For this question only, include your commute time to and from your home and work and commute time between jobs. 60 In the LAST MONTH, how often did your daytime work hours begin at or before 5 AM? Please choose only one of the following: Nearly every day 3-4 times per week 1-2 times per week 3-4 times per month 1-2 times per month Never Not applicable - I don't work during the day 61 How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? Please choose the appropriate response for each item: No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting and reading: Watching tv: Sitting inactivein a public place (e.g. a theater or a meeting): As a passenger in a car for an hour without a break: Lying down to rest in the afternoon when circumstances permit:
130 No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting and talking to someone: In a car, while stopped for a few minutes in traffic: While at work during a night shift: While at work during a day or evening shift: This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. 62 Have you been told that you snore? Please choose only one of the following: Yes No Don't know 63 Youâve been told that your snoring is: Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '62 [62]' (Have you been told that you snore?) Please choose only one of the following: Slightly louder than breathing As loud as talking Louder than talking Very loud, can be heard in adjacent room Don't know 64 Youâve been told that you snore: Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '62 [62]' (Have you been told that you snore?) Please choose only one of the following: Nearly every night 3-4 times per week 1-2 times per week 1-2 times per month
131 Rarely Never Don't know 65 Have you been told that your snoring ever bothered other people? Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '62 [62]' (Have you been told that you snore?) Please choose only one of the following: Yes No 66 Has anyone told you that you quit breathing during your sleep? Please choose only one of the following: Yes No 67 If you quit breathing in your sleep, how often does this occur? Please choose only one of the following: Nearly every day 3-4 times per week 1-2 times per week 1-2 times per month Rarely Never I don't quit breathing in my sleep Don't know 68 I feel tired or fatigued immediately upon awakening: Please choose only one of the following: Nearly every day 3-4 times per week 1-2 times per week 1-2 times per month
132 Rarely Never 69 During my waking hours, I feel tired or fatigued Please choose only one of the following: Nearly every day 3-4 times per week 1-2 times per week 1-2 times per month Rarely Never 70 I have nodded off or fallen asleep while driving a vehicle. Please choose only one of the following: Yes No 71 If you have nodded off or fallen asleep while driving a vehicle, how often does this occur? Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '70 [70]' (I have nodded off or fallen asleep while driving a vehicle.) Please choose only one of the following: Nearly every day 3-4 times per week 1-2 times per week 1-2 times per month Rarely Never
133 72 This scale is intended to record your own assessment of any sleep difficulty you might have experienced. For each of the following questions, please select the answer that describes your sleep experiences/difficulties that have occurred AT LEAST 3 TIMES PER WEEK during the PAST MONTH. 73 Tme it takes you to fall asleep after turning off the lights Please choose only one of the following: No problem Slightly delayed Markedly delayed Very delayed or did not sleep at all 74 Awakenings after having fallen asleep Please choose only one of the following: No problem Minor problem Considerable problem Serious problem or did not sleep at all 75 Final awakening earlier than desired Please choose only one of the following: Not earlier A little earlier Markedly earlier Much earlier or did not sleep at all 76 Total sleep duration Please choose only one of the following: Sufficient Slightly insufficient Markedly insufficient
134 Very insufficient or did not sleep at all 77 Overall quality of sleep (no matter how long you slept) Please choose only one of the following: Satisfactory Slightly unsatisfactory Markedly unsatisfactory Very unsatisfactory or did not sleep at all 78 Sense of well-being during the time you are awake Please choose only one of the following: Normal Slightly decreased Markedly decreased Very decreased 79 Functioning (physical and mental) during the time you are awake Please choose only one of the following: Normal Slightly decreased Markedly decreased Very decreased 80 Sleepiness during the time you are awake Please choose only one of the following: None Mild Considerable Intense Submit Your Survey. Thank you for completing this survey.