NHTSA Form 1219 Morning Evening Questionnaire

OMB Control No. 2127-0682

Expiration Date 02/28/2015

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

Morning/Evening Phone Screening

Because we are conducting a study to determine how sleep impacts driving performance, the following questions ask you about your sleep patterns. Your answer will determine if you continue to meet the study qualifications. We need participants with a variety of levels and patterns of sleep, so there are no right or wrong answers. Please respond as honestly and accurately as you can.

1. Considering your own “feeling beat” rhythm, at what time would you get up if you were entirely free to plan your day?

5:00 AM-6:30 AM—5 points

6:30 AM-7:45 AM—4 points

7:45 AM-9:45 AM—3 points

9:45 AM-11:00 AM—2 points

11:00 AM-12:00 PM—1 point

2. During the first half hour after woken in the morning, how tired do you feel?

Very tired—1 point

Fairly Tired—2 points

Fairly refreshed—3 points

Very refreshed—4 Points

3. At what time in the evening do you feel tired and as a result in need of sleep?

8:00 PM - 9:00 PM—5 points

9:00 PM - 10:15 PM—4 points

10:15PM - 12:45 AM—3 points

12:45 AM- 2:00 AM —2 points

2:00 AM- 3:00 AM—1 point

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

5:00 AM – 8:00 AM – 5 points

8:00 AM – 10:00 AM – 4 points

10:00 AM – 5:00 PM – 3 points

5:00 PM – 10:00 PM – 2 points

10:00 PM – 5:00 AM – 1 point

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

Definitely a “morning” type—6 points

Rather more a “morning” than an evening type—4 points

Rather more a “evening” than a “morning” type —2 points

Definitely a “evening” type”—0 Points

Scores 12 and above include in study and proceed to General Health Exclusion Criteria (page 3 Phone screening procedures)

Scores 11 and below will not be included in study, proceed to Closing (page 6 Phone Screening Procedures)

NHTSA Form 1219 Page 2