Form 1466 Sleep diary

OMB Control Number: 2127-XXX

Expiration Date: XX/XX/XXXX

Form 1466

The EMS Sleep Health and Fatigue Education Study Sleep Diary

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 XXXX-XXXX (expiration date: MM/DD/YYYY). The average amount of time to complete this survey is 3 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.

Name: ___________________. Today’s Date: ______________. Current Time (military time e.g., 2130):_______________.

I tried to go to sleep at (e.g., 10/5/2017 at 2230): _______________________________________.

I actually fell to sleep at (e.g., 2245): ____________________.

I got out of bed at (e.g., 10/6/2017 at 0630): ________________________________________________.

I actually woke up at (e.g., 0605): ______________________.

Fill in the boxes below to indicate when you were sleeping

Example

1200	1300	1400	1500	1600	1700	1800	1900	2000	2100	2200		2300	0000	0100	0200	0300	0400	0500	0600		0700	0800	0900	1000	1100	1200

Shade in your sleep here

1200	1300	1400	1500	1600	1700	1800	1900	2000	2100	2200	2300	0000	0100	0200	0300	0400	0500	0600	0700	0800	0900	1000	1100	1200

The number of times that my sleep was disturbed or disrupted was (e.g., 2): _______________.

The overall quality of my sleep was (select one):

Very Good
Fairly Good
Fairly Bad
Very Bad

NHTSA Form 1466