OMB Appendix J Characteristics questionnaire

Instructions

You will receive $10 for fully completing this one-time questionnaire, which will be paid upon completion of your time in the study. This questionnaire can be completed at any point during your time in the study. Please note that this questionnaire is in addition to the 15-item questionnaire you will complete on each of the five mornings during your time in the study, and it provides different information.

When you have completed this questionnaire, place it in the box with other questionnaires and study equipment when you ship everything back to us.

This questionnaire includes a total of 35 questions. The first 10 questions measure your usual sleep over the past month. Questions 11 to 29 are used to determine if you are a “morning type” or an “evening type”. The last 6 questions are related to noise in your bedroom, how you are affected by noise.

Read each question carefully, and answer each question as honestly as possible. Do not go back and check your answers, your first response is usually the most accurate. There are no correct or incorrect answers. Please answer all questions.

Instructions

The following 10 questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month. Please answer all questions.

Questions

1. During the past month, what time have you usually gone to bed at night?

BED TIME ___________

2. During the past month, how long (in minutes) has it usually taken you to fall asleep each night?

NUMBER OF MINUTES ___________

3. During the past month, what time have you usually gotten up in the morning?

GETTING UP TIME ___________

4. During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours you spent in bed.)

HOURS OF SLEEP PER NIGHT ___________

For each of the remaining questions, check the one best response. Please answer all questions.

5. During the past month, how often have you had trouble sleeping because you . . .	Not during the past month ↓	Less than once a week ↓	Once or twice a week ↓	Three or more times a week ↓
Cannot get to sleep within 30 minutes	□	□	□	□
Wake up in the middle of the night or early morning	□	□	□	□
Have to get up to use the bathroom	□	□	□	□
Cannot breathe comfortably	□	□	□	□
Cough or snore loudly	□	□	□	□
Feel too cold	□	□	□	□
Feel too hot	□	□	□	□
Had bad dreams	□	□	□	□
Have pain	□	□	□	□
Other reason(s), please describe:	□	□	□	□

6. During the past month, how would you rate your sleep quality overall?

Very good ↓	Fairly good ↓	Fairly bad ↓	Very bad ↓
□	□	□	□

7. During the past month, how often have you taken medicine to help you sleep (prescribed or "over the counter")?

Not during the past month ↓	Less than once a week ↓	Once or twice a week ↓	Three or more times a week ↓
□	□	□	□

8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?

Not during the past month ↓	Less than once a week ↓	Once or twice a week ↓	Three or more times a week ↓
□	□	□	□

9. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?

No problem at all ↓	Only a very slight problem ↓	Somewhat of a problem ↓	A very big problem ↓
□	□	□	□

10. Do you have a bed partner or room mate?

No bed partner or room mate ↓	Partner/room mate in other room ↓	Partner in same room, but not same bed ↓	Partner in same bed ↓
□	□	□	□

If you have a room mate or bed partner, ask him/her how often in the past month you have had . . .

a) Loud snoring

Not during the past month ↓	Less than once a week ↓	Once or twice a week ↓	Three or more times a week ↓
□	□	□	□

b) Long pauses between breaths while asleep

Not during the past month ↓	Less than once a week ↓	Once or twice a week ↓	Three or more times a week ↓
□	□	□	□

c) Legs twitching or jerking while you sleep

Not during the past month ↓	Less than once a week ↓	Once or twice a week ↓	Three or more times a week ↓
□	□	□	□

d) Episodes of disorientation or confusion during sleep

Not during the past month ↓	Less than once a week ↓	Once or twice a week ↓	Three or more times a week ↓
□	□	□	□

e) Other restlessness while you sleep; please describe__________________________________________

_____________________________________________________________________________________

Not during the past month ↓	Less than once a week ↓	Once or twice a week ↓	Three or more times a week ↓
□	□	□	□

Instructions

The following 19 questions are used to determine if you are a “morning type” or an “evening type”. Please answer all questions.

Questions

11. What time would you get up if you were entirely free to plan your day?

5:00 – 6:29 am ↓	6:30 – 7:44 am ↓	7:45 – 9:44 am ↓	9:45 – 10:59 am ↓	11:00 – 11:59 am ↓	Midday – 5:00 am ↓
□	□	□	□	□	□

12. What time would you go to bed if you were entirely free to plan your evening?

8:00 – 8:59 pm ↓	9:00 – 10:14 pm ↓	10:15 pm – 12:29 am ↓	12:30 – 1:44 am ↓	1:45 – 2:59 am ↓	3:00 am – 8:00 pm ↓
□	□	□	□	□	□

13. If there is a specific time at which you have to get up in the morning, to what extent do you depend on being woken up by an alarm clock?

Not at all dependent ↓	Slightly dependent ↓	Fairly dependent ↓	Very dependent ↓
□	□	□	□

14. How easy do you find it to get up in the morning (when you are not woken up unexpectedly)?

Not at all easy ↓	Not very easy ↓	Fairly easy ↓	Very easy ↓
□	□	□	□

15. How alert do you feel during the first half hour after you wake up in the morning?

Not at all alert ↓	Slightly alert ↓	Fairly alert ↓	Very alert ↓
□	□	□	□

16. How hungry do you feel during the first half-hour after you wake up in the morning?

Not at all hungry ↓	Slightly hungry ↓	Fairly hungry ↓	Very hungry ↓
□	□	□	□

17. During the first half-hour after you wake up in the morning, how tired do you feel?

Very tired ↓	Fairly tired ↓	Fairly refreshed ↓	Very refreshed ↓
□	□	□	□

18. If you have no commitment the next day, what time would you go to bed compared to your usual bedtime?

Seldom or never later ↓	Less than one hour later ↓	1-2 hours later ↓	More than two hours later ↓
□	□	□	□

19. You have decided to engage in some physical exercise. A friend suggests that you do this for one hour twice a week and the best time for him/her is between 7:00 – 8:00 am. Bearing in mind nothing but your own internal “clock”, how do you think you would perform?

Would be in good form ↓	Would be in reasonable form ↓	Would find it difficult ↓	Would find it very difficult ↓
□	□	□	□

20. At what time of day do you feel you become tired as a result of need for sleep?

8:00 – 8:59 pm ↓	9:00 – 10:14 pm ↓	10:15 pm – 12:44 am ↓	12:45 – 1:59 am ↓	2:00 – 3:00 am ↓
□	□	□	□	□

21. You want to be at your peak performance for a test that you know is going to be mentally exhausting and will last for two hours. You are entirely free to plan your day. Considering only your own internal “clock”, which ONE of the four testing times would you choose?

8:00 – 10:00 ↓	11:00 am – 1:00 pm ↓	3:00 – 5:00 pm ↓	7:00 – 9:00 pm ↓
□	□	□	□

22. If you got into bed at 11:00 pm, how tired would you be?

Not at all tired ↓	A little tired ↓	Fairly tired ↓	Very tired ↓
□	□	□	□

23. For some reason, you have gone to bed several hours later than usual, but there is no need to get up at any particular time the next morning. Which ONE of the following are you most likely to do?

Will wake up at usual time, but will NOT fall back asleep ↓	Will wake up at usual time and will doze thereafter ↓	Will wake up at usual time but will fall asleep again ↓	Will NOT wake up until later than usual ↓
□	□	□	□

24. One night you have to remain awake between 4:00 – 6:00 am in order to carry out a night watch. You have no commitments the next day. Which ONE of the alternatives will suite you best?

Would NOT go to bed until watch was over ↓	Would take a nap before and sleep after ↓	Would take a good sleep before and nap after ↓	Would sleep only before watch ↓
□	□	□	□

25. You have to do two hours of hard physical work. You are entirely free to plan your day and considering only your own internal “clock” which ONE of the following times would you choose?

8:00 – 10:00 ↓	11:00 am – 1:00 pm ↓	3:00 – 5:00 pm ↓	7:00 – 9:00 pm ↓
□	□	□	□

26. You have decided to engage in hard physical exercise. A friend suggests that you do this for one hour twice a week and the best time for him/her is between 10:00 – 11:00 pm. Bearing in mind nothing else but your own internal “clock”, how well do you think you would perform?

Would be in good form ↓	Would be in reasonable form ↓	Would find it difficult ↓	Would find it very difficult ↓
□	□	□	□

27. Suppose that you can choose your school hours. Assume that you went to school for five hours per day and that school was interesting and enjoyable. Which five consecutive hours would you select?

5 hours starting between 4:00 – 7:59 am ↓	5 hours starting between 8:00 – 8:59 am ↓	5 hours starting between 9:00 am – 1:59 pm ↓	5 hours starting between 2:00 – 4:59 pm ↓	5 hours starting between 5:00 pm – 3:59 am ↓
□	□	□	□	□

28. At what time of the day do you think that you reach your “feeling best” peak?

5:00 – 7:59 am ↓	8:00 – 9:59 am ↓	10:00 am – 4:59 pm ↓	5:00 – 9:59 pm ↓	10:00 pm – 4:59 am ↓
□	□	□	□	□

29. One hears about “morning” and “evening” types of people. Which ONE of these types do you consider yourself to be?

Definitely a “morning” type ↓	Rather more a “morning” type than an “evening” type ↓	Rather more an “evening” type than a “morning” type ↓	Definitely an “evening” type ↓
□	□	□	□

Questions

The following 6 questions relate to how you are affected by noise and noise in your bedroom. Please answer all questions.

30. During the last month or so, how often have you done the following because of noise when trying to sleep at home?
	Never ↓	Rarely ↓	Sometimes ↓	Often ↓	Always ↓
Wear earplugs or headphones	□	□	□	□	□
Use alcohol	□	□	□	□	□
Use medication	□	□	□	□	□
Turn on the TV	□	□	□	□	□
Turn on music	□	□	□	□	□
Close windows	□	□	□	□	□
Use a sound machine	□	□	□	□	□
Turn on a fan	□	□	□	□	□

31. Thinking about the last 12 months or so, when you are here at home, how much does noise from the following sources disturb your sleep?
	Not at all ↓	Slightly ↓	Moderately ↓	Very ↓	Extremely ↓
Road traffic	□	□	□	□	□
Railway traffic	□	□	□	□	□
Industry/factories	□	□	□	□	□
Construction	□	□	□	□	□
Neighbors	□	□	□	□	□
Air conditioning	□	□	□	□	□

32. Try to imagine yourself in the given situation and respond spontaneously without spending too much time considering whether or not you generally agree with a given statement. For each statement place a cross in the box which best describes your opinion.
	Strongly disagree ↓	Slightly disagree ↓	Slightly agree ↓	Strongly agree ↓
I need an absolutely quiet environment to get a good night's sleep.	□	□	□	□
I need quiet surroundings to be able to work on new tasks	□	□	□	□
When I am at home, I habituate to noise quickly.	□	□	□	□
I become very agitated if I can hear someone talking while I am trying to fall asleep.	□	□	□	□
I am very sensitive to neighbourhood noise.	□	□	□	□
When people around me are noisy I don’t get on with my work.	□	□	□	□
I am sensitive to noise.	□	□	□	□
My performance is much worse in noisy places.	□	□	□	□
I do not feel well rested if there has been a lot of noise the night before.	□	□	□	□
It would not bother me to live in a noisy street.	□	□	□	□
For a quiet place to live I would accept other disadvantages.	□	□	□	□
I need peace and quiet to do difficult work.	□	□	□	□
I can fall asleep even when it is noisy.	□	□	□	□

33. Has your current residence received any sound proofing treatment to reduce noise?	34. Do you have an air conditioner in your bedroom?	No unit	□
Yes □		Window unit	□
No □		Central air conditioner	□
35. Do you regularly use any medications and/or supplements (including herbal supplements)?
Yes □
No □ If you answered yes, please list all medications and/or supplements that you use regularly: _________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

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