AppendixB.OMB.2021.4.30

Appendix B: Survey (Baseline, Immediate Post-training and Post-training @ 1, 3, and 6 months)

BASELINE SURVEY

Date ________

1. What is your age?

________

2. Which of the following best represents how you think of yourself?

___ Gay / lesbian or gay

             ___ Straight, that is, not gay / lesbian or gay

             ___ Bisexual

             ___ Something else

             ___ I don’t know the answer

3. What sex were you assigned at birth, on your original birth certificate?

___ Male

___ Female

___ Refused

___ I don’t know

4. Do you currently describe yourself as male, female, or transgender?

___ Male

___ Female

___ Transgender

___ None of these

5. Which one of the following would you say is your ethnicity?

___Hispanic or Latino

___Not Hispanic or Latino

6. Which one or more of the following would you say is your race?

___American Indian or Alaska Native

___Asian

___Black or African American

___Native Hawaiian or Other Pacific Islander

___White

7. Are you…

___Married

___Divorced

___Widowed

___Separated

___Never Married

___A member of an unmarried couple

8. How many children less than 18 years of age live in your household?

_________

9. What is your highest degree or year of school you completed?

___Diploma

___Associate degree in nursing

___Completed Baccalaureate degree in another discipline

___Baccalaureate degree in Nursing

___Completed graduate degree (Master's or Doctorate)

10. How long have you been working as a registered nurse?

___Less than 1 year

___1 to 5 years

___6 to 10 years

___11 or more years

11. Do you have any jobs besides your main job or do any other work for pay?

___Yes

___No

12. How many hours did you work LAST WEEK at ALL jobs or businesses?

13. What type of patient care facility do you work?

___Acute care hospital

___Urgent Care

___Post-acute facility (e.g., skilled nursing facility, long-term care, rehabilitation)

___Other

14. What is your primary unit or work area? Think of your “unit” as the work area, department, or clinical area where you spend most of your work time.

___Multiple Units/No specific unit

___Medical/Surgical (including cardiology, gastroenterology, oncology/hematology, pulmonology, telemetry units)

___Emergency Department/Observation/Short Stay

___ICU (all adult types)

___Labor & Delivery,

___Obstetrics & Gynecology

___Pediatrics (including NICU, PICU)

___Psychiatry, Behavioral Health

___Surgical services (endoscopy, colonoscopy, pre-op, operating room, PACU/post-op, peri-op)

___Skilled Nursing, Long-term care, Rehabilitation

___Hospice

___Other

15. Which of the following best describes the shift length you usually work at your main job?

___8 hours

___10 hours

___12 hours

___16 hours

___other

16. One hears about “morning” and “evening” types of people. Which one of these types do you consider yourself to be?

___Definitely a morning type

___Rather more a morning than an evening type

___Rather more an evening than a morning type

___Definitely an evening type

17. Please respond to each item by marking one box per row.

In the past 7 days...
	Very Poor	Poor	Fair	Good	Very good
My sleep quality was	5	4	3	2	1
	Not at all	A little bit	Somewhat	Quite a bit	Very much
My sleep was refreshing	5	4	3	2	1
I had a problem with my sleep	1	2	3	4	5
I had difficulty falling asleep	1	2	3	4	5
My sleep was restless	1	2	3	4	5
I tried hard to get to sleep	1	2	3	4	5
I worried about not being able to fall asleep	1	2	3	4	5
I was satisfied with my sleep	5	4	3	2	1

18. Please respond to each item by marking one box per row.

In the past 7 days...

	Not at all	A little bit	Somewhat	Quite a bit	Very much
I had a hard time getting things done because I was sleepy	1	2	3	4	5
I felt alert when I woke up	5	4	3	2	1
I felt tired	1	2	3	4	5
I had problems during the day because of poor sleep	1	2	3	4	5
I had a hard time concentrating because of poor sleep	1	2	3	4	5
I felt irritable because of poor sleep	1	2	3	4	5
I was sleepy during the daytime	1	2	3	4	5
I had trouble staying awake during the day	1	2	3	4	5

19. During the past month...

have you felt burned out from your work?	Yes	No
have you worried that your work is hardening you emotionally?	Yes	No
have you often been bothered by feeling down, depressed, or hopeless?	Yes	No
have you fallen asleep while sitting inactive in a public place?	Yes	No
have you felt that all the things you had to do were piling up so high that you could not overcome them?	Yes	No
have you been bothered by emotional problems (such as feeling anxious, depressed, or irritable)?	Yes	No
has your physical health interfered with your ability to do your daily work at home and/or away from home?	Yes	No

20. Please rate how much you agree with the following statements:

The work I do is meaningful to me

1- Very strongly disagree

2

3

4

5

6

7- Very strongly agree

My work schedule leaves me enough time for my personal/family life

___Strongly agree ___agree ___neutral ___disagree ___strongly disagree

SURVEY FOR IMMEDIATE POST-TRAINING

1. How strongly do you agree or disagree with the following statements:

I intend to use behaviors to promote sleep by improving sleep hygiene (e.g. improved sleep environment, taking naps, adjusting caffeine intake)	1 Disagree	2 Somewhat disagree	3 Neither agree nor disagree	4 Somewhat agree	5 Agree
I intend to use behaviors to promote sleep by changing my work environment (e.g., schedule adjustments, less overtime, etc.)	1 Disagree	2 Somewhat disagree	3 Neither agree nor disagree	4 Somewhat agree	5 Agree

2. What did you like about the training program?

3. What could improve in the training program?

SURVEY FOR POST-TRAINING (1, 3, AND 6-MONTHS)

1. Please respond to each item by marking one box per row.

In the past 7 days...
	Very Poor	Poor	Fair	Good	Very good
My sleep quality was	5	4	3	2	1
	Not at all	A little bit	Somewhat	Quite a bit	Very much
My sleep was refreshing	5	4	3	2	1
I had a problem with my sleep	1	2	3	4	5
I had difficulty falling asleep	1	2	3	4	5
My sleep was restless	1	2	3	4	5
I tried hard to get to sleep	1	2	3	4	5
I worried about not being able to fall asleep	1	2	3	4	5
I was satisfied with my sleep	5	4	3	2	1

2. Please respond to each item by marking one box per row.

In the past 7 days...

	Not at all	A little bit	Somewhat	Quite a bit	Very much
I had a hard time getting things done because I was sleepy	1	2	3	4	5
I felt alert when I woke up	5	4	3	2	1
I felt tired	1	2	3	4	5
I had problems during the day because of poor sleep	1	2	3	4	5
I had a hard time concentrating because of poor sleep	1	2	3	4	5
I felt irritable because of poor sleep	1	2	3	4	5
I was sleepy during the daytime	1	2	3	4	5
I had trouble staying awake during the day	1	2	3	4	5

3. During the past month...

have you felt burned out from your work?	Yes	No
have you worried that your work is hardening you emotionally?	Yes	No
have you often been bothered by feeling down, depressed, or hopeless?	Yes	No
have you fallen asleep while sitting inactive in a public place?	Yes	No
have you felt that all the things you had to do were piling up so high that you could not overcome them?	Yes	No
have you been bothered by emotional problems (such as feeling anxious, depressed, or irritable)?	Yes	No
has your physical health interfered with your ability to do your daily work at home and/or away from home?	Yes	No

4. Please rate how much you agree with the following statements:

The work I do is meaningful to me

1- Very strongly disagree

2

3

4

5

6

7- Very strongly agree

My work schedule leaves me enough time for my personal/family life

___Strongly agree ___agree ___neutral ___disagree ___strongly disagree

5. Since taking the NIOSH online training for nurses, what strategies to improve sleep were you able to implement?

6. What in your personal and/or professional experience made it easy for you to implement these strategies?

7. What in your personal and/or professional experience prevented you from implementing strategies to improve your sleep?

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