Form NHTSA Form 1719 NHTSA Form 1719 Karolinska Sleepiness Scale

OMB Control Number: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Karolinska Sleepiness Scale (KSS)

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control number. The OMB Control Number for this information collection is XXXX-XXXX (expiration date: MM/DD/YYYY). Public reporting for this collection of information is estimated to be approximately 1 minute per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590

Date and Time of Administration

Extremely alert Very alert

Which best describes you right now? 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

Extremely sleepy, can't keep awake

NHTSA Form 1719