Field Study: Morning Survey

National Sleep Study

Appendix_K_Field_study_morning_survey

Field Study: Morning Survey

OMB: 2120-0798

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Shape1 Shape2 Morning questionnaire

Instructions

  • Please mark all answers clearly

    Shape3 Shape4 Shape5
  • 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

Shape6



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?


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AuthorMichael Smith
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File Created2021-04-16

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