0920-23HM Daily Pre-Shift Questionnaires

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Participant ID: _________________

Assessing Fatigue and Fatigue Management in U.S. Onshore Oil and Gas Extraction:

Pre-Shift Questionnaire

National Institute for Occupational Safety and Health

1. Date (MM/DD/YYYY):

2. Time (HH:MM): __________ AM / PM

3. If you worked yesterday, what time did you get back to your residence (i.e. the place you sleep during your work rotation)?

1. Time (HH:MM): _______ A.M. P.M.

2. I did not work yesterday

3. Prefer not to say

4. When did you leave for work today?

Time (HH:MM): _______ A.M. P.M.

5. How did you get to the worksite?

1. Driver

2. Passenger in a co-worker’s vehicle

3. Passenger in a company-provided vehicle

4. Other (specify):

5. Prefer not to say

6. Did you sleep on the way to work, even for a little while?

1. Yes

2. No

3. Prefer not to say

7. When are you starting your shift? (HH:MM): __________ AM / PM

8. Not counting the commute to work, please answer the questions about the last time you slept before your shift today

1. What time did you go to bed? ______ A.M. P.M.

2. How long did it take you to fall asleep? ______ Min. Hrs.

3. How many times did you wake up

after falling asleep? ______

4. How long were you awake in total? ______ Min. Hrs.

5. What time did you wake up? ______ A.M. P.M.

6. What time did you get out of bed? ______ A.M. P.M.

7. How would you rate the quality of your sleep?

Very Poor Very Good

9. Did you just sleep in employer-provided housing?

1. Yes

2. No

3. Prefer not to say

10. [IF 6=Yes] What type of housing?

1. Man camp

2. Hotel or motel

3. Apartment or house

4. Other (please specify):

5. Prefer not to say

 

11. Please describe the place you just slept:

	Strongly agree	Agree	Unsure	Disagree	Strongly disagree
The place I sleep is usually physically comfortable
The place I sleep is usually at a comfortable temperature
The place I sleep is usually quiet at night
The place I sleep is usually dark

12. Please select the number that indicates your sleepiness in the past five minutes:

Very alert	1
	2
Alert-normal level	3
	4
Neither alert nor sleepy	5
	6
Sleepy, but no effort to keep awake	7
	8
Very sleepy, great effort to keep awake	9

13. Indicate how stressed you feel on the small ruler.

None As bad as it

could be

Public reporting burden of this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-XXXX).