Form 1461 Individual level screening form

OMB Control Number: 2127-XXX

Expiration Date: XX/XX/XXXX

Form 1461

The EMS Sleep Health and Fatigue Education Study

EMS Clinician Telephone Screening Form

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control number. The OMB Control Number for this information collection is 2127-XXX (expiration date: MM/DD/YYYY). The average amount of time to complete this survey is 5 minutes. All responses to this collection of information are voluntary. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden send them to Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

Thank you for your interest in this research study. In order to determine if you are eligible to participate, we need to ask you a few questions.

YES	NO	Question
		[1] Are you 18 years of age or older?
		[2] Do you live in the United States (Hawaii & Alaska included)?
		[3] Are you a licensed/certified EMS professional (e.g., EMT-basic, Firefighter, Paramedic, Flight nurse, etc.)?
		[4] Do you currently work shifts (e.g., 8-hour, 12hour, 16-hour, 24-hour, Kelly Shift, or other)?
		[5] Do you work at least one shift per week?
		[6] Do you currently own and use a cellular phone or smart phone that can both send and receive text messages?
		[7] Are you willing to answer online surveys and willing to respond to text-message queries for 7 days in a row every third week of the month for a total of 24 weeks/6 months?
		[8] Are you willing to answer a follow up survey at the end of the study period?
		[9] Do you currently work as a full-time or part-time EMS clinician at an EMS agency that has agreed to participate in this research study.

For any NO responses, read this: “Thank you for your interest. You answered NO to at least one question. We will need to consult with the research study’s principal investigator to make a final determination of your eligibility. Do you have a preferred email address that we can use to contact you with the final decision?

Name: ________________________________________.

Email: _________________________________________.

If all responses are YES, then read the following: “We have determined that you are eligible to participate in this research study. Please now go to the study website www.emssleephealth.pitt.edu and click on the “Interested?” tab in the middle of the website. Please answer the questions on that webpage and follow the instructions for signing up and enrolling in this research study.

If you have any questions please contact the study team at: XXXXXXX@pitt.edu or 412-###-####. Participation in this study is completely voluntary.

Thank you.

NHTSA Form 1461