NHTSA Form 1221 Retrospective Sleepiness

OMB Control No. 2127-XXXX

Expiration Date XX/XX/XXXX

Study: DRIIVE

Participant: _________

Visit: ________

Form Number:_________

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

Degree of Sleepiness	Scale Rating
Feeling active, vital, alert, or wide awake	1
Functioning at high levels, but not at peak; able to concentrate	2
Awake, but relaxed; responsive but not fully alert	3
Somewhat foggy, let down	4
Foggy; losing interest in remaining awake; slowed down	5
Sleepy, woozy, fighting sleep; prefer to lie down	6
No longer fighting sleep, sleep onset soon; having dream-like thoughts	7
Asleep	8

Please rate your degree of sleepiness as you began to drive: _____

Please rate your degree of sleepiness at the left turn in the urban environment: _____

Please rate your degree of sleepiness on the on-ramp to the interstate: _____

Please rate your degree of sleepiness at the interchange on the interstate: _____

Please rate your degree of sleepiness at the stop sign on the off-ramp
from the interstate: _____

Please rate your degree of sleepiness as drove through the sharp curve the
rural environment: _____

Please rate your degree of sleepiness as you passed the service station at the
Y-intersection: _____

Please rate your degree of sleepiness at the start of the gravel road: _____

Please rate your degree of sleepiness at start of the long straight away: _____

Please rate your degree of sleepiness just before you were told to stop: _____

Degree of Sleepiness	Scale Rating
Feeling active, vital, alert, or wide awake	1
Functioning at high levels, but not at peak; able to concentrate	2
Awake, but relaxed; responsive but not fully alert	3
Somewhat foggy, let down	4
Foggy; losing interest in remaining awake; slowed down	5
Sleepy, woozy, fighting sleep; prefer to lie down	6
No longer fighting sleep, sleep onset soon; having dream-like thoughts	7
Asleep	8

Draw a line between the ratings to indicate your leveal of sleepiness for the times between the points of intersted that are listed.

NHTSA Form 1221 Page 4