OMB Appendix K Field study morning survey

Morning questionnaire

Instructions

• Please mark all answers clearly

  

• If the question is multiple choice, mark your answer by placing an x in the box:

• If there are no response alternatives listed, write in your response in the provided space

1. Current date: ___________________ Current time:___________________

2. In the 6 hours before you went to bed did you drink any alcohol?

• Yes

• No

3. In the 6 hours before you went to bed did you drink any caffeine (e.g. coffee, tea, soda)?

• Yes

• No

4. In the 6 hours before you went to bed did you use any medications or supplements (herbal or otherwise)?

• Yes. If yes, please list the medication and/or supplements used: ______________

__________________________________________________________________

• No

5. Thinking about yesterday, how stressful was your day?

				
Not at all	Slightly	Moderately	Very	Extremely

6. Last night, did you sleep with the windows...

• Closed

• Partially open

• Completely open

7. Last night, did somebody share the bed with you (e.g. partner, child, pet)?

• Yes

• No

8. At what time did you...

go to bed and switch off the light last night? ______________ (Hour: Minute)

wake up this morning? ______________ (Hour: Minute)

get out of bed this morning? ______________ (Hour: Minute)

9. How long did it take you to fall asleep after you turned the lights off?

____________________(minutes)

10. Did you wake up during the night?

• Yes

• No

If so, how many times? ________________

What were the reasons, please describe:___________________________________________

___________________________________________________________________________

11. How do you feel right now?

				
Very refreshed and rested	Refreshed and rested	Neither refreshed nor tired	Tired	Very tired

12. Please check the box next to the statement that best describes how sleepy you feel right now...

• Extremely alert

• Very alert

• Alert

• Rather alert

• Neither alert nor sleepy

• Some signs of sleepiness

• Sleepy, but no effort to keep awake

• Sleepy, some effort to keep awake

• Very sleepy, great effort to keep awake, fighting sleep

13. Thinking about last night, how would you rate your sleep quality overall?

□ Very good

□ Fairly good

□ Neither good nor bad

□ Fairly bad

□ Very bad

14. Thinking about last night, how much did noise from aircraft disturb your sleep?

				
Not at all	Slightly	Moderately	Very	Extremely

15. Other comments?

............................................................................................................................................

............................................................................................................................................

............................................................................................................................................

If you have any questions or concerns please call us at 555-555-5555

4