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pdfOMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Form 1465
Follow-up Survey
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 25 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.
NHTSA Form Number 1465
1
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
EMS Sleep Health Study
NHTSA Form Number 1465
2
EMS Sleep Health Study
NHTSA Form Number 1465
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Pittsburgh Sleep Quality Index (PSQI).
Source: Buysse DJ, Reynolds CF, 3rd, Monk TH, Berman SR,
Kupfer DJ. The Pittsburgh Sleep Quality Index: a new
instrument for psychiatric practice and research. Psychiatry
Res. May 1989;28(2):193-213
3
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
Questions from the Pittsburgh Sleep Quality
Index (PSQI). Source: Buysse DJ, Reynolds CF,
3rd, Monk TH, Berman SR, Kupfer DJ. The
Pittsburgh Sleep Quality Index: a new
instrument for psychiatric practice and
research. Psychiatry Res. May 1989;28(2):193213
NHTSA Form Number 1465
4
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
Questions from the Pittsburgh Sleep Quality
Index (PSQI). Source: Buysse DJ, Reynolds CF,
3rd, Monk TH, Berman SR, Kupfer DJ. The
Pittsburgh Sleep Quality Index: a new
instrument for psychiatric practice and
research. Psychiatry Res. May 1989;28(2):193213
NHTSA Form Number 1465
5
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
Questions from the Pittsburgh Sleep
Quality Index (PSQI). Source: Buysse DJ,
Reynolds CF, 3rd, Monk TH, Berman SR,
Kupfer DJ. The Pittsburgh Sleep Quality
Index: a new instrument for psychiatric
practice and research. Psychiatry Res.
May 1989;28(2):193-213
NHTSA Form Number 1465
6
EMS Sleep Health Study
NHTSA Form Number 1465
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Epworth Sleepiness Scale (ESS):
Source: Johns MW. A new method for measuring daytime
sleepiness: the Epworth sleepiness scale. Sleep. 1991
Dec;14(6):540-5. PubMed PMID: 1798888.
7
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
NHTSA Form Number 1465
Questions from the Chalder Fatigue Questionnaire:
Source: Chalder T, et al. Development of a fatigue scale. J
Psychosom Res. 1993;37(2):147-153
8
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
NHTSA Form Number 1465
Questions from the Chalder Fatigue Questionnaire:
Source: Chalder T, et al. Development of a fatigue scale. J
Psychosom Res. 1993;37(2):147-153
9
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
NHTSA Form Number 1465
Questions from the Chalder Fatigue Questionnaire:
Source: Chalder T, et al. Development of a fatigue scale. J
Psychosom Res. 1993;37(2):147-153
10
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
Questions from the EMS Safety Attitudes Questionnaire
(EMS-SAQ): Source: Patterson et al. Variation in
emergency medical services workplace safety culture.
Prehosp Emerg Care. 2010; 14(4):448-460
NHTSA Form Number 1465
11
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the EMS Safety Attitudes Questionnaire
(EMS-SAQ): Source: Patterson et al. Variation in
emergency medical services workplace safety culture.
Prehosp Emerg Care. 2010; 14(4):448-460
NHTSA Form Number 1465
12
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
NHTSA Form Number 1465
Questions from the EMS Safety Attitudes Questionnaire
(EMS-SAQ): Source: Patterson et al. Variation in
emergency medical services workplace safety culture.
Prehosp Emerg Care. 2010; 14(4):448-460
13
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
NHTSA Form Number 1465
Questions from the EMS Safety Attitudes Questionnaire
(EMS-SAQ): Source: Patterson et al. Variation in
emergency medical services workplace safety culture.
Prehosp Emerg Care. 2010; 14(4):448-460
14
EMS Sleep Health Study
NHTSA Form Number 1465
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the EMS Safety Attitudes Questionnaire
(EMS-SAQ): Source: Patterson et al. Variation in
emergency medical services workplace safety culture.
Prehosp Emerg Care. 2010; 14(4):448-460
15
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the EMS Safety Attitudes Questionnaire
(EMS-SAQ): Source: Patterson et al. Variation in
emergency medical services workplace safety culture.
Prehosp Emerg Care. 2010; 14(4):448-460
NHTSA Form Number 1465
16
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
Questions from the Schedule Attitudes Survey (SAS):
Source: Dunham RB, Pierce JL. Attitudes toward work
schedules: Construct definition, instrument development,
and validation. Academy of Management Journal. 1986.
We incorporate items from the general affect subscale
(items 1 & 2) and the social and family life subscale (items
3-5). Response options include a 5-point Likert scale from
strongly disagree to strongly agree.
NHTSA Form Number 1465
17
OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
NHTSA Form Number 1465
Questions from the The Occupational Fatigue,
Exhaustion, Recovery Scale (OFER): Source: Winwood PC,
et al. Development and validation of a scale to measure
work-related fatigue and recovery: the Occupational
Fatigue Exhaustion/Recovery Scale (OFER). J Occup
Environ Med. Jun 2005;47(6):594-606.
Winwood PC, Lushington K, Winefield AH. Further
development and validation of the Occupational Fatigue
Exhaustion Recovery (OFER) scale. J Occup Environ Med.
Apr 2006;48(4):381-389].
18
EMS Sleep Health Study
NHTSA Form Number 1465
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the The Occupational Fatigue,
Exhaustion, Recovery Scale (OFER): Source: Winwood PC,
et al. Development and validation of a scale to measure
work-related fatigue and recovery: the Occupational
Fatigue Exhaustion/Recovery Scale (OFER). J Occup
Environ Med. Jun 2005;47(6):594-606.
Winwood PC, Lushington K, Winefield AH. Further
development and validation of the Occupational Fatigue
Exhaustion Recovery (OFER) scale. J Occup Environ Med.
Apr 2006;48(4):381-389].
19
EMS Sleep Health Study
NHTSA Form Number 1465
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the The Occupational Fatigue,
Exhaustion, Recovery Scale (OFER): Source: Winwood PC,
et al. Development and validation of a scale to measure
work-related fatigue and recovery: the Occupational
Fatigue Exhaustion/Recovery Scale (OFER). J Occup
Environ Med. Jun 2005;47(6):594-606.
Winwood PC, Lushington K, Winefield AH. Further
development and validation of the Occupational Fatigue
Exhaustion Recovery (OFER) scale. J Occup Environ Med.
Apr 2006;48(4):381-389].
20
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
21
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
22
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
23
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
24
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
25
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
26
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
27
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
28
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
29
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
30
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
31
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
32
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
33
EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
NHTSA Form Number 1465
34
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX
EMS Sleep Health Study
NHTSA Form Number 1465
35
| File Type | application/pdf |
| File Title | Form 1006 Study Website & Follow up Surveys |
| Author | Patterson, P. Daniel |
| File Modified | 2018-08-28 |
| File Created | 2018-08-28 |