Form Approved
OMB No. 0920-XXXX
Exp. Date XX/XX/XXX
Smartphone Questions
Sleep Log
I went to bed at?
I got out of bed at?
Karolinska Sleepiness Scale (KSS)
How sleepy are you now?
󠆯 Extremely alert
󠆯
󠆯 Alert
󠆯
󠆯 Neither alert nor sleepy
󠆯
󠆯 Sleepy, but no effort to stay awake
󠆯
󠆯 Extremely sleepy – fighting sleep
Stress Scale (SS)
󠆯 Not stressed
󠆯
󠆯
󠆯
󠆯 Very Stressed
Fatigue Scale (FS)
󠆯 Alert
󠆯
󠆯
󠆯
󠆯 Tired
Difficulty of Drive
󠆯 Easy
󠆯
󠆯
󠆯
󠆯 Difficult
Public reporting burden of this collection of information is estimated to average 1 minute per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
Safety Hazards
󠆯 Few
󠆯
󠆯
󠆯
󠆯 Many
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Foley, Tamekia (CDC/NIOSH/OD/ODDM) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |