Form NHTSA Form 1720 NHTSA Form 1720 Sleep and Food Intake

OMB Control Number: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Sleep And Food Intake (SFI)

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 5 minutes 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

What time do you normally go to bed?

Your answer will use a 24-hour clock, meaning 10:00pm (24-hour clock) would be 22:00. Please ask the researcher for help if

needed.

What time do you normally wake up?

Your answer will use a 24-hour clock, meaning 6:00am (24-hour clock) would be 06:00. Please ask the researcher for help if

needed.

What time did you go to sleep last night?

Your answer will use a 24-hour clock, meaning 10:00pm (24-hour clock) would be 22:00. Please ask the researcher for help if

needed.

What time did you wake today?

Your answer will use a 24-hour clock, meaning 6:00am (24-hour clock) would be 06:00. Please ask the researcher for help if

needed.

In total, how many hours did you sleep last night?	0 < 1 1
	1.5
	2
	2.5
	3
	3.5
	4
	4.5
	5
	5.5
	6
	6.5
	7
	7.5
	8
	8.5
	9
	9.5
	10
	10.5
	11
	11.5
	12
	12.5
	13
Do you feel that you got enough sleep last night?	Yes No
Do you feel that you are currently well-rested?	Yes No
Did you take a nap today?	Yes No
When did you take your nap?
Your answer will use a 24-hour clock, meaning 1:00pm would be 13:00. Please ask the researcher for help if needed.
When did you eat your last meal?
Your answer will use a 24-hour clock, meaning 1:00pm would be 13:00. Please ask the researcher for help if needed.
What did you eat at that meal?

Have you had anything to eat since your last meal? Yes No

When did you eat that?

Your answer will use a 24-hour clock, meaning 1:00pm (24-hour clock) would be 13:00. Please ask the researcher for help if

needed.

What did you have to eat since your last meal?

Have you had any nicotine in the last 24 hours? Yes No

When did you last have nicotine in the last 24 hours?

Your answer will use a 24-hour clock, meaning 1:00pm (24-hour clock) would be 13:00. Please ask the researcher for help if

needed.

When else in the past 24 hours have you used nicotine?

Please type your responses using the 24-hour clock. If you have only used once in the past 24 hours and that time was entered above, please indicate "NA" here.

How many cigarettes did you smoke?

How much chewing tobacco did you use?

Other forms of nicotine? (type and frequency)

Have you had any caffeine in the last 24 hours? Yes No

When did you last have caffeine in the last 24 hours?

Your answer will use a 24-hour clock, meaning 1:00pm (24-hour clock) would be 13:00. Please ask the researcher for help if

needed.

When else in the past 24 hours have you used caffeine?

Please type your responses using the 24-hour clock. If you have only used caffeine once in the past 24 hours and that time was entered above, please indicate "NA" here.

How many cups of coffee did you drink?

How many cans of caffeinated soda did you drink?

Other forms of caffeine? (type and frequency)

Have you had any alcohol in the last 24 hours? Yes No

When did you last have alcohol?

Your answer will use a 24-hour clock, meaning 1:00pm (24-hour clock) would be 13:00. Please ask the researcher for help if

needed.

How many cans of beer did you drink?

How many glasses of wine did you drink?

How many mixed drinks did you consume?

How many shots of alcohol did you consume?

Have you taken any recreational substances, such as Yes

cannabis, in the last 24 hours? No

Have you taken any prescription or over-the-counter Yes

medications or supplements (including herbal) in the No past 24 hours?

Please explain what was taken, how much was taken, and when it was taken (using 24-hour clock format).

Researcher Initials

NHTSA Form 1720