Form 1463 Baseline Survey

Form 1463
Baseline Survey
Screenshots

OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

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 XXXXXXXX (expiration date: MM/DD/YYYY). The average amount of time to complete this survey is 145 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.

NHTSA Form Number 1463

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Home page

NHTSA Form Number 1463

OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

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Interested/Screening Page

NHTSA Form Number 1463

OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

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OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Are you willing to answer online surveys and willing to respond to text-message queries for 7 days in a row every third week of the month for a total of 24 weeks/6 months?
study period?
Do you currently work as a full-time or part-time EMS clinician at an EMS agency that has agreed to participate in this research study?

NHTSA Form Number 1463

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OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Video version of IRB-approved consent
form

NHTSA Form Number 1463

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OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

emssleephealth.pitt.edu

5555555555
[email protected]

NHTSA Form Number 1463

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OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

The welcoming text
message from the
study’s data collection
platform.

NHTSA Form Number 1463

Welcome to the EMS Sleep
Health Study

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OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Initial email from data
collection system with
temporary password
included

NHTSA Form Number 1463

Thank you for consenting to participate in the study!
Your new password is New081343.
You can log back into www.emssleephealth.pitt.edu to
continue the study process.

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Back to website and click on already enrolled
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

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OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

EMS Sleep Health Study

EMS Sleep Health Study

EMS Sleep Health Study

EMS Sleep Health Study

EMS Sleep Health Study main page

NHTSA Form Number 1463

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Back to website and click on already enrolled to
login with new password
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

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OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

EMS Sleep Health Study
EMS Sleep Health Study

NHTSA Form Number 1463

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OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Answer Baseline Survey

NHTSA Form Number 1463

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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

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EMS Sleep Health Study

Questions asked of
participant if he/she
responds to question
5a indicating that
he/she works more
than one job.

NHTSA Form Number 1463

OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

Physical activity
questions from the
BRFSS Physical Activity
Rotating Core

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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

Questions from the Pittsburgh Sleep Quality Index (PSQI).
Source: Buysse DJ, Reynolds CF, 3rd, Monk TH, Berman SR,
Kupfer DJ. The Pittsburgh Sleep Quality Index: a new
instrument for psychiatric practice and research. Psychiatry
Res. May 1989;28(2):193-213

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EMS Sleep Health Study

OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Pittsburgh Sleep Quality
Index (PSQI). Source: Buysse DJ, Reynolds CF,
3rd, Monk TH, Berman SR, Kupfer DJ. The
Pittsburgh Sleep Quality Index: a new
instrument for psychiatric practice and
research. Psychiatry Res. May 1989;28(2):193213

NHTSA Form Number 1463

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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Pittsburgh Sleep Quality
Index (PSQI). Source: Buysse DJ, Reynolds CF,
3rd, Monk TH, Berman SR, Kupfer DJ. The
Pittsburgh Sleep Quality Index: a new
instrument for psychiatric practice and
research. Psychiatry Res. May 1989;28(2):193213

NHTSA Form Number 1463

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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Pittsburgh Sleep
Quality Index (PSQI). Source: Buysse DJ,
Reynolds CF, 3rd, Monk TH, Berman SR,
Kupfer DJ. The Pittsburgh Sleep Quality
Index: a new instrument for psychiatric
practice and research. Psychiatry Res.
May 1989;28(2):193-213

NHTSA Form Number 1463

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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

Questions from the Epworth Sleepiness Scale (ESS):
Source: Johns MW. A new method for measuring daytime
sleepiness: the Epworth sleepiness scale. Sleep. 1991
Dec;14(6):540-5. PubMed PMID: 1798888.
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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

Questions from the Chalder Fatigue Questionnaire:
Source: Chalder T, et al. Development of a fatigue scale. J
Psychosom Res. 1993;37(2):147-153
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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

Questions from the Chalder Fatigue Questionnaire:
Source: Chalder T, et al. Development of a fatigue scale. J
Psychosom Res. 1993;37(2):147-153
28

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

Questions from the Chalder Fatigue Questionnaire:
Source: Chalder T, et al. Development of a fatigue scale. J
Psychosom Res. 1993;37(2):147-153
29

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the EMS Safety Attitudes Questionnaire
(EMS-SAQ): Source: Patterson et al. Variation in
emergency medical services workplace safety culture.
Prehosp Emerg Care. 2010; 14(4):448-460

NHTSA Form Number 1463

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EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the EMS Safety Attitudes Questionnaire
(EMS-SAQ): Source: Patterson et al. Variation in
emergency medical services workplace safety culture.
Prehosp Emerg Care. 2010; 14(4):448-460

NHTSA Form Number 1463

31

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

Questions from the EMS Safety Attitudes Questionnaire
(EMS-SAQ): Source: Patterson et al. Variation in
emergency medical services workplace safety culture.
Prehosp Emerg Care. 2010; 14(4):448-460
32

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

Questions from the EMS Safety Attitudes Questionnaire
(EMS-SAQ): Source: Patterson et al. Variation in
emergency medical services workplace safety culture.
Prehosp Emerg Care. 2010; 14(4):448-460
33

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

Questions from the EMS Safety Attitudes Questionnaire
(EMS-SAQ): Source: Patterson et al. Variation in
emergency medical services workplace safety culture.
Prehosp Emerg Care. 2010; 14(4):448-460
34

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the EMS Safety Attitudes Questionnaire
(EMS-SAQ): Source: Patterson et al. Variation in
emergency medical services workplace safety culture.
Prehosp Emerg Care. 2010; 14(4):448-460

NHTSA Form Number 1463

35

EMS Sleep Health Study

OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Schedule Attitudes Survey (SAS):
Source: Dunham RB, Pierce JL. Attitudes toward work
schedules: Construct definition, instrument development,
and validation. Academy of Management Journal. 1986.
We incorporate items from the general affect subscale
(items 1 & 2) and the social and family life subscale (items
3-5). Response options include a 5-point Likert scale from
strongly disagree to strongly agree.

NHTSA Form Number 1463

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EMS Sleep Health Study

NHTSA Form Number 1463

OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the The Occupational Fatigue,
Exhaustion, Recovery Scale (OFER): Source: Winwood PC,
et al. Development and validation of a scale to measure
work-related fatigue and recovery: the Occupational
Fatigue Exhaustion/Recovery Scale (OFER). J Occup
Environ Med. Jun 2005;47(6):594-606.
Winwood PC, Lushington K, Winefield AH. Further
development and validation of the Occupational Fatigue
Exhaustion Recovery (OFER) scale. J Occup Environ Med.
Apr 2006;48(4):381-389].
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EMS Sleep Health Study

NHTSA Form Number 1463

OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the The Occupational Fatigue,
Exhaustion, Recovery Scale (OFER): Source: Winwood PC,
et al. Development and validation of a scale to measure
work-related fatigue and recovery: the Occupational
Fatigue Exhaustion/Recovery Scale (OFER). J Occup
Environ Med. Jun 2005;47(6):594-606.
Winwood PC, Lushington K, Winefield AH. Further
development and validation of the Occupational Fatigue
Exhaustion Recovery (OFER) scale. J Occup Environ Med.
Apr 2006;48(4):381-389].
38

EMS Sleep Health Study

NHTSA Form Number 1463

OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the The Occupational Fatigue,
Exhaustion, Recovery Scale (OFER): Source: Winwood PC,
et al. Development and validation of a scale to measure
work-related fatigue and recovery: the Occupational
Fatigue Exhaustion/Recovery Scale (OFER). J Occup
Environ Med. Jun 2005;47(6):594-606.
Winwood PC, Lushington K, Winefield AH. Further
development and validation of the Occupational Fatigue
Exhaustion Recovery (OFER) scale. J Occup Environ Med.
Apr 2006;48(4):381-389].
39

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

40

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

41

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

42

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

43

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411
44

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

45

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

46

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

47

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

48

EMS Sleep Health Study

OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

49

EMS Sleep Health Study

OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

50

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

51

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

52

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

Questions from the Sleep Fatigue and Alertness Behavior
survey (SFAB): Source:
Patterson et al, Emergency healthcare worker sleep,
fatigue, and alertness behavior survey (SFAB):
development and content validation of a survey tool.
Accid Anal Prev. 2014; 73:399-411

NHTSA Form Number 1463

53

EMS Sleep Health Study
OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1463

54

EMS Sleep Health Study

OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

EMS Sleep Health Study

NHTSA Form Number 1463

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OMB Control Number: 2127-XXX
Expiration Date: XX/XX/XXXX

EMS Sleep Health Study

NHTSA Form Number 1463

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