NHTSA Form 1223 Pre-Drive Sleep and Intake Questionnaire

OMB Control No. 2127-XXXX

Expiration Date XX/XX/XXXX

Study: DRIIVE

Participant:______

Visit: _____

Date__________

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a 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-XXXX.  Public reporting for this collection of information is estimated to be approximately 5 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information.  All responses to this collection of information are voluntary.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590

Sleep and Food Intake Survey

As part of this study, it is useful to collect information about your sleep and food, alcohol, and caffeine intake. Please read each question carefully. If something is unclear, ask the researcher for assistance. Your participation is voluntary and you have the right to omit questions if you choose.

1. On a typical _____________, when do you normally go to bed? ______AM/ PM

2. On a typical _____________, when do you normally wake up? ______AM/ PM

3. What time did you go to sleep last night? ___________ AM/PM

4. What time did you wake today? ___________ AM/PM

5. In total, how many hours did you sleep last night? _______

6. Do you feel that you got enough sleep? No Yes

7. Did you take a nap today?

 No

 Yes, times? _____________________

8. When did you eat your last meal? _____________AM/PM

1. What did you eat at that meal? ____________________________________________________________________________________________________________________________

9. Have you had anything to eat since your last meal?

 No

 Yes, when? _____________AM/PM

1. What did you eat? __________________________________________

10. Have you had any nicotine in the last 24 hours?

 No

 Yes, when? ______________ AM/PM

1. How many cigarettes did you smoke? __________________________

2. How much chewing tobacco did you use? _______________________

3. Other forms of nicotine? (type and frequency) ____________________

11. Have you had any caffeine in the last 24 hours?

 No

 Yes, when? ______________ AM/PM

1. How many cups of coffee did you drink? ________________________

2. How many cans of caffeinated soda did you drink? ________________

3. Other forms of caffeine? (type and frequency) ____________________

12. Have you had any alcohol in the last 24 hours?

 No

 Yes, when? ______________ AM/PM

1. How many cans of beer did you drink?___________________________

2. How many glasses of wine did you drink? ________________________

3. How many mixed drinks did you consume? _______________________

4. How many shots of alcohol did you consume? _____________________

13. Have you taken any prescription or over-the-counter medications in the past 24 hours?

 No

 Yes, Explain what was taken, how much was taken and when it was taken.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

NHTSA Form 1223 Page 5