Sleep and Activities Diary with Psychomotor Vigilance Te

[NIOSH] Reducing Fatigue Among Taxi/Rideshare Drivers

Attachment 7a - Sleep and Activities Diary with PVT

OMB: 0920-1413

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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.







File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMenendez, Cammie Chaumont (CDC/NIOSH/DSR/AFEB)
File Modified0000-00-00
File Created2023-10-02

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