Sleep and Activities Diary with Psychomotor Vigilance Te

Data Collection Period # ____

Form Approved OMB No. 0920-xxxx Exp. Date xx/xx/xxxx SLEEP AND ACTIVITIES DIARY CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing 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).
ACTIVITY	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Wake up time:	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm
Sleepiness rating	___	___	___	___	___	___	___
Fatigue rating	___	___	___	___	___	___	___
PVT score	___	___	___	___	___	___	___
During sleep period:
Number of times awake	____	____	____	____	____	____	____
Total time spent awake (estimate)	____hrs ____min	____hrs ____min	____hrs ____min	____hrs ____min	____hrs ____min	____hrs ____min	____hrs ____min
Cause? (e.g., stress, sick)	__________	__________	__________	__________	__________	__________	__________
Did you fall back asleep?	Yes No	Yes No	Yes No	Yes No	Yes No	Yes No	Yes No
After waking up:
4 hrs after wakeup	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm
Sleepiness rating	___	___	___	___	___	___	___
Fatigue rating	___	___	___	___	___	___	___
PVT score	___	___	___	___	___	___	___
8 hrs after wakeup	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm
Sleepiness rating	___	___	___	___	___	___	___
Fatigue rating	___	___	___	___	___	___	___
PVT score	___	___	___	___	___	___	___
12 hrs after wakeup
Sleepiness rating	___	___	___	___	___	___	___
Fatigue rating	___	___	___	___	___	___	___
PVT score	___	___	___	___	___	___	___
At bedtime:	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm
Sleepiness rating	___	___	___	___	___	___	___
Fatigue rating	___	___	___	___	___	___	___
PVT score	___	___	___	___	___	___	___

Use the following fatigue and sleepiness ratings for your responses.

FATIGUE RATING:

1 = extremely alert, wide awake, feeling motivated to work

2 = very alert, lively, responsive, but not at peak, very easy to think and function

3 = alert, somewhat refreshed, easy to think about what you are doing

4 = fairly alert, able to think about what you are doing

5 = neither tired nor alert, not feeling refreshed

6 = somewhat tired, dragging

7 = tired, difficult to think about what you are doing

8 = very tired, some exhaustion, very difficult to think or function

9 = extremely tired, completely exhausted, cannot function or think clearly

SLEEPINESS RATING:

1 = extremely alert

2 = very alert

3 = alert

4 = fairly alert

5 = neither sleepy nor alert

6 = some signs of sleepiness

7 = sleepy, but no effort to stay alert

8 = very sleepy, some effort to keep alert

9 = extremely sleepy, fighting sleep, great effort to stay alert

Complete the sleep and activities diary the best you can. Week of ________ / ___ - ___ / 20__
ACTIVITY	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Activities start time	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm
Drove taxi/rideshare today?	Yes No	Yes No	Yes No	Yes No	Yes No	Yes No	Yes No
Shift start time	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm
How many miles driven?	______ miles	______ miles	______ miles	______ miles	______ miles	______ miles	______ miles
How long did you drive?	____hrs ____min	____hrs ____min	____hrs ____min	____hrs ____min	____hrs ____min	____hrs ____min	____hrs ____min
How much $ in fares?	$_______	$_______	$_______	$_______	$_______	$_______	$_______
How much $$ in tips?	$_______	$_______	$_______	$_______	$_______	$_______	$_______
How many trips done?	____	____	____	____	____	____	____
Number of breaks	____	____	____	____	____	____	____
1.Break time Break length	__:__ am pm ____ min	__:__ am pm ____ min	__:__ am pm ____ min	__:__ am pm ___ min	__:__ am pm ____ min	__:__ am pm ___ min	__:__ am pm ___ min
2.Break time Break length	__:__ am pm ____ min	__:__ am pm ____ min	__:__ am pm ____ min	__:__ am pm ___ min	__:__ am pm ____ min	__:__ am pm ___ min	__:__ am pm ___ min
3.Break time Break length	__:__ am pm ____ min	__:__ am pm ____ min	__:__ am pm ____ min	__:__ am pm ___ min	__:__ am pm ____ min	__:__ am pm ___ min	__:__ am pm ___ min
Number of naps taken	___	___	___	___	___	___	___
1.Nap time Nap length	__:__ am pm ____ min	__:__ am pm ____ min	__:__ am pm ____ min	__:__ am pm ___ min	__:__ am pm ____ min	__:__ am pm ___ min	__:__ am pm ___ min
2.Nap time Nap length	__:__ am pm ____ min	__:__ am pm ____ min	__:__ am pm ____ min	__:__ am pm ___ min	__:__ am pm ____ min	__:__ am pm ___ min	__:__ am pm ___ min
3.Nap time Nap length	__:__ am pm ____ min	__:__ am pm ____ min	__:__ am pm ____ min	__:__ am pm ___ min	__:__ am pm ____ min	__:__ am pm ___ min	__:__ am pm ___ min
Shift end time	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm	__:__ am pm
How much caffeinated coffee?	___ cups	___ cups	___ cups	___ cups	___ cups	___ cups	___ cups
Other caffeine product? (like soda, tea, pills)	__________	__________	__________	__________	__________	__________	__________
How much alcohol?	____ drinks	____ drinks	____ drinks	____ drinks	____ drinks	____ drinks	____ drinks
How many tobacco products?	____ Type: ______	____ Type: ______	____ Type: ______	____ Type: ______	____ Type: ______	____ Type: ______	____ Type: ______
Medications taken during day?	__________ __________	__________ __________	__________ __________	__________ __________	__________ __________	__________ __________	__________ __________
Medications taken just before bedtime?	___________ ___________	___________ ___________	___________ ___________	__________ __________	___________ ___________	__________ __________	___________ ___________
General level of work activity: Mild, mod, high	___________	___________	___________	__________	___________	__________	___________
Did you experience or witness a traumatic or stressful event today?	No Yes, describe:	No Yes, describe:	No Yes, describe:	No Yes, describe	No Yes, describe:	No Yes, describe	No Yes, describe

Use the following definition of alcoholic dosages for your responses.

Standard Dosage of Alcoholic Drinks:

1 beer = 12 oz.

1 glass wine = 5 oz.

1 shot of distilled spirits/liquor = 1.5 oz.

[Proceed to the Psychomotor Vigilance Test]

Figure 1. Screenshots. PVT-B performed on the smartphone data collection app.