OMB Control Number: 2127-NEW
Expiration Date: MM/DD/YYYY
ACTIVITY LOG
INSTRUCTIONS TO PARTICIPANT
Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to 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-NEW (expiration date: MM/DD/YYYY). The average amount of time to complete the screening is 30 minutes. All responses to this collection of information are voluntary. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden send them to Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.
You will use this log to document your activity in the days preceding your study visit. You are asked to record the following types of information:
About your sleep
About your food and beverage consumption
About your activities throughout the day
Asleep column: place an X in the time slots for when were asleep. To do this, place an X in the log at the time you lay down to sleep. When you awake, place another X.
Activity column: provide brief comments about what you were doing during that time frame. For example, if you went to the gym, write gym. Also, record if you wake up during the night and for how long you are awake. You should complete this column when you complete the activity.
Food/beverage column: Provide brief comments about what food and beverages you consumed throughout the day. Please make special note of anything that you eat or drink that contains caffeine or alcohol. You should complete this column when you complete the meal/snack.
Items with caffeine include: coffee, soda, tea, energy drinks, energy bars, vitamin water, food containing chocolate, candy
Alcohol items include: beer, wine, liquor/spirits
Pages 2-3 provide you with an example of how to complete your log.
Be specific, but try to keep your answers as brief as possible. If you have questions about completing your activity log, please contact Rose Schmitt at (319) 335-4666.
REMEMBER:
Refrain from consuming any alcohol 24 hours prior to ALL your driving sessions.
After 1:00 PM on the day of your overnight visit, restrict beverage intake to water. This does not include Vitamin Water, which contains caffeine.
Refrain from sleep, including taking naps, beginning at 8 AM on the day of your overnight visit.
Activity Log Example: DATE: 01/01/2019
Time |
|
Asleep |
Activity |
Food/Beverage |
12:00-12:15 |
AM |
X |
|
|
12:15-12:30 |
AM |
X |
|
|
12:30-12:45 |
AM |
X |
|
|
12:45-1:00 |
AM |
X |
|
|
1:00-1:15 |
AM |
X |
|
|
1:15-1:30 |
AM |
X |
|
|
1:30-1:45 |
AM |
X |
|
|
1:45-2:00 |
AM |
X |
|
|
2:00-2:15 |
AM |
X |
|
|
2:15-2:30 |
AM |
X |
|
|
2:30-2:45 |
AM |
X |
|
|
2:45-3:00 |
AM |
X |
|
|
3:00-3:15 |
AM |
X |
|
|
3:15-3:30 |
AM |
X |
Woke up |
|
3:30-3:45 |
AM |
X |
| |
|
3:45-4:00 |
AM |
X |
| |
|
4:00-4:15 |
AM |
X |
|
|
4:15-4:30 |
AM |
X |
|
|
4:30-4:45 |
AM |
X |
|
|
4:45-5:00 |
AM |
X |
|
|
5:00-5:15 |
AM |
X |
|
|
5:15-5:30 |
AM |
X |
|
|
5:30-5:45 |
AM |
X |
Woke up |
|
5:45-6:00 |
AM |
X |
|
|
6:00-6:15 |
AM |
X |
|
|
6:15-6:30 |
AM |
X |
|
|
6:30-6:45 |
AM |
|
Gym |
20 oz. PowerAde |
6:45-7:00 |
AM |
|
| |
Energy Bar |
7:00-7:15 |
AM |
|
| |
|
7:15-7:30 |
AM |
|
| |
|
7:30-7:45 |
AM |
|
At work |
|
7:45-8:00 |
AM |
|
| |
|
8:00-8:15 |
AM |
|
| |
|
8:15-8:30 |
AM |
|
| |
|
8:30-8:45 |
AM |
|
| |
|
8:45-9:00 |
AM |
|
| |
12 oz. Latte Starbucks |
9:00-9:15 |
AM |
|
| |
|
9:15-9:30 |
AM |
|
| |
|
9:30-9:45 |
AM |
|
| |
|
9:45-10:00 |
AM |
|
| |
|
10:00-10:15 |
AM |
|
| |
|
10:15-10:30 |
AM |
|
| |
|
10:30-10:45 |
AM |
|
| |
|
10:45-11:00 |
AM |
|
| |
|
11:00-11:15 |
AM |
|
| |
|
11:15-11:30 |
AM |
|
| |
|
11:30-11:45 |
AM |
|
| |
|
11:45-12:00 |
AM/PM |
|
Lunch |
Chocolate cake, turkey sandwich, Chips, |
Time |
|
Asleep |
Activity |
Food/Beverage |
12:00-12:15 |
PM |
|
| |
16 oz. Pepsi |
12:15-12:30 |
PM |
|
| |
|
12:30-12:45 |
PM |
|
| |
|
12:45-1:00 |
PM |
|
At Work |
|
1:00-1:15 |
PM |
|
| |
|
1:15-1:30 |
PM |
|
| |
|
1:30-1:45 |
PM |
|
| |
|
1:45-2:00 |
PM |
|
| |
|
2:00-2:15 |
PM |
|
| |
|
2:15-2:30 |
PM |
|
| |
|
2:30-2:45 |
PM |
|
| |
Snickers Bar |
2:45-3:00 |
PM |
|
| |
|
3:00-3:15 |
PM |
|
| |
|
3:15-3:30 |
PM |
|
| |
|
3:30-3:45 |
PM |
|
| |
|
3:45-4:00 |
PM |
|
| |
|
4:00-4:15 |
PM |
|
| |
|
4:15-4:30 |
PM |
|
| |
|
4:30-4:45 |
PM |
|
Drinks |
2 Red Bull and Vodka |
4:45-5:00 |
PM |
|
| |
|
5:00-5:15 |
PM |
|
| |
|
5:15-5:30 |
PM |
|
| |
|
5:30-5:45 |
PM |
|
| |
|
5:45-6:00 |
PM |
|
Making Dinner @ home |
|
6:00-6:15 |
PM |
|
| |
|
6:15-6:30 |
PM |
|
| |
|
6:30-6:45 |
PM |
|
Eating Dinner |
1 Glass of wine |
6:45-7:00 |
PM |
|
| |
Lasagna |
7:00-7:15 |
PM |
|
Watching TV |
Salad |
7:15-7:30 |
PM |
|
| |
|
7:30-7:45 |
PM |
|
| |
|
7:45-8:00 |
PM |
|
| |
|
8:00-8:15 |
PM |
|
| |
2 scoops Coffee ice cream |
8:15-8:30 |
PM |
|
| |
|
8:30-8:45 |
PM |
|
Reading in Bed |
|
8:45-9:00 |
PM |
|
| |
|
9:00-9:15 |
PM |
|
| |
|
9:15-9:30 |
PM |
X |
|
|
9:30-9:45 |
PM |
X |
|
|
9:45-10:00 |
PM |
X |
|
|
10:00-10:15 |
PM |
X |
|
|
10:15-10:30 |
PM |
X |
|
|
10:30-10:45 |
PM |
X |
|
|
10:45-11:00 |
PM |
X |
|
|
11:00-11:15 |
PM |
X |
|
|
11:15-11:30 |
PM |
X |
|
|
11:30-11:45 |
PM |
X |
|
|
11:45-12:00 |
PM |
X |
|
|
Activity Log Date (Day Prior to Study Visit): ____________
Time |
|
Activity |
Food/Beverage |
8:00-8:15 |
AM |
|
|
8:15-8:30 |
AM |
|
|
8:30-8:45 |
AM |
|
|
8:45-9:00 |
AM |
|
|
9:00-9:15 |
AM |
|
|
9:15-9:30 |
AM |
|
|
9:30-9:45 |
AM |
|
|
9:45-10:00 |
AM |
|
|
10:00-10:15 |
AM |
|
|
10:15-10:30 |
AM |
|
|
10:30-10:45 |
AM |
|
|
10:45-11:00 |
AM |
|
|
11:00-11:15 |
AM |
|
|
11:15-11:30 |
AM |
|
|
11:30-11:45 |
AM |
|
|
11:45-12:00 |
AM/PM |
|
|
12:00-12:15 |
PM |
|
|
12:15-12:30 |
PM |
|
|
12:30-12:45 |
PM |
|
|
12:45-1:00 |
PM |
|
|
1:00-1:15 |
PM |
|
|
1:15-1:30 |
PM |
|
|
1:30-1:45 |
PM |
|
|
1:45-2:00 |
PM |
|
|
2:00-2:15 |
PM |
|
|
2:15-2:30 |
PM |
|
|
2:30-2:45 |
PM |
|
|
2:45-3:00 |
PM |
|
|
3:00-3:15 |
PM |
|
|
3:15-3:30 |
PM |
|
|
3:30-3:45 |
PM |
|
|
3:45-4:00 |
PM |
|
|
4:00-4:15 |
PM |
|
|
4:15-4:30 |
PM |
|
|
4:30-4:45 |
PM |
|
|
4:45-5:00 |
PM |
|
|
5:00-5:15 |
PM |
|
|
5:15-5:30 |
PM |
|
|
5:30-5:45 |
PM |
|
|
5:45-6:00 |
PM |
|
|
6:00-6:15 |
PM |
|
|
6:15-6:30 |
PM |
|
|
6:30-6:45 |
PM |
|
|
6:45-7:00 |
PM |
|
|
7:00-7:15 |
PM |
|
|
7:15-7:30 |
PM |
|
|
7:30-7:45 |
PM |
|
|
7:45-8:00 |
PM |
|
|
8:00-8:15 |
PM |
|
|
8:15-8:30 |
PM |
|
|
8:30-8:45 |
PM |
|
|
8:45-9:00 |
PM |
|
|
9:00-9:15 |
PM |
|
|
9:15-9:30 |
PM |
|
|
9:30-9:45 |
PM |
|
|
9:45-10:00 |
PM |
|
|
10:00-10:15 |
PM |
|
|
10:15-10:30 |
PM |
|
|
10:30-10:45 |
PM |
|
|
10:45-11:00 |
PM |
|
|
11:00-11:15 |
PM |
|
|
11:15-11:30 |
PM |
|
|
11:30-11:45 |
PM |
|
|
11:45-12:00 |
PM |
|
|
Date (Day of Study Visit):_______________ |
|||
12:00-12:15 |
AM |
|
|
12:15-12:30 |
AM |
|
|
12:30-12:45 |
AM |
|
|
12:45-1:00 |
AM |
|
|
1:00-1:15 |
AM |
|
|
1:15-1:30 |
AM |
|
|
1:30-1:45 |
AM |
|
|
1:45-2:00 |
AM |
|
|
2:00-2:15 |
AM |
|
|
2:15-2:30 |
AM |
|
|
2:30-2:45 |
AM |
|
|
2:45-3:00 |
AM |
|
|
3:00-3:15 |
AM |
|
|
3:15-3:30 |
AM |
|
|
3:30-3:45 |
AM |
|
|
3:45-4:00 |
AM |
|
|
4:00-4:15 |
AM |
|
|
4:15-4:30 |
AM |
|
|
4:30-4:45 |
AM |
|
|
4:45-5:00 |
AM |
|
|
5:00-5:15 |
AM |
|
|
5:15-5:30 |
AM |
|
|
5:30-5:45 |
AM |
|
|
5:45-6:00 |
AM |
|
|
6:00-6:15 |
AM |
|
|
6:15-6:30 |
AM |
|
|
6:30-6:45 |
AM |
|
|
6:45-7:00 |
AM |
|
|
7:45-8:00 |
AM |
|
|
8:00-8:15 |
AM |
|
|
8:15-8:30 |
AM |
|
|
8:30-8:45 |
AM |
|
|
8:45-9:00 |
AM |
|
|
9:00-9:15 |
AM |
|
|
9:15-9:30 |
AM |
|
|
9:30-9:45 |
AM |
|
|
9:45-10:00 |
AM |
|
|
10:00-10:15 |
AM |
|
|
10:15-10:30 |
AM |
|
|
10:30-10:45 |
AM |
|
|
10:45-11:00 |
AM |
|
|
11:00-11:15 |
AM |
|
|
11:15-11:30 |
AM |
|
|
11:30-11:45 |
AM |
|
|
11:45-12:00 |
AM/PM |
|
|
12:00-12:15 |
PM |
|
|
12:15-12:30 |
PM |
|
|
12:30-12:45 |
PM |
|
|
12:45-1:00 |
PM |
|
|
1:00-1:15 |
PM |
|
|
1:15-1:30 |
PM |
|
|
1:30-1:45 |
PM |
|
|
1:45-2:00 |
PM |
|
|
2:00-2:15 |
PM |
|
|
2:15-2:30 |
PM |
|
|
2:30-2:45 |
PM |
|
|
2:45-3:00 |
PM |
|
|
3:00-3:15 |
PM |
|
|
3:15-3:30 |
PM |
|
|
3:30-3:45 |
PM |
|
|
3:45-4:00 |
PM |
|
|
4:00-4:15 |
PM |
|
|
4:15-4:30 |
PM |
|
|
4:30-4:45 |
PM |
|
|
4:45-5:00 |
PM |
|
|
5:00-5:15 |
PM |
|
|
5:15-5:30 |
PM |
|
|
5:30-5:45 |
PM |
|
|
5:45-6:00 |
PM |
|
|
6:00-6:15 |
PM |
|
|
6:15-6:30 |
PM |
|
|
6:30-6:45 |
PM |
|
|
6:45-7:00 |
PM |
|
|
7:00-7:15 |
PM |
|
|
7:15-7:30 |
PM |
|
|
7:30-7:45 |
PM |
|
|
7:45-8:00 |
PM |
|
|
8:00-8:15 |
PM |
|
|
8:15-8:30 |
PM |
|
|
8:30-8:45 |
PM |
|
|
8:45-9:00 |
PM |
|
|
NHTSA Form 1445
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | In this study you will be asked to complete a diary card each day |
| Author | Judith Wightman |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |