Study: ___________ OMB Control Number: 2127-NEW
Participant: _______ Expiration Date: XX/XX/XXXX
Date: ____________
Sleep Survey
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 survey is 10 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.
As part of this study, we collect information about your sleep patterns. 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.
On a typical _____________, when do you normally go to bed? ______AM/ PM
On a typical _____________, when do you normally wake up? ______AM/ PM
Do you feel that you got enough sleep? No Yes
NHTSA Form 1446
| File Type | application/msword |
| Author | croe |
| Last Modified By | SYSTEM |
| File Modified | 2018-11-07 |
| File Created | 2018-11-07 |