0920-23HM Daily Post-Shift Questionnaires

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Participant ID: _______________

Assessing Fatigue and Fatigue Management in U.S. Onshore Oil and Gas Extraction:

Post-Shift Questionnaire

National Institute for Occupational Safety and Health

1. Date (MM/DD/YYYY):

2. Time (HH:MM): __________ AM / PM

3. When is the end of your shift? (HH:MM): __________ AM / PM

4. How will you get back to your residence (that is, the place you sleep during your work rotation)?

1. Driver

2. Passenger in a co-worker’s vehicle

3. Passenger in a company-provided vehicle

4. Other (specify):

5. Prefer not to say

5. Do you plan to sleep on the way back to your residence, even for a little while?

1. Yes

2. No

3. Prefer not to say

6. Please select the number that indicates your sleepiness in the past five minutes:

Very alert	1
	2
Alert-normal level	3
	4
Neither alert nor sleepy	5
	6
Sleepy, but no effort to keep awake	7
	8
Very sleepy, great effort to keep awake	9

7. About how many breaks did you take during your workday? Please include formal breaks, informal breaks, or downtime (e.g., between stages).

1. No breaks

2. 1 break

3. 2 breaks

4. 3 or more breaks

5. Prefer not to say

8. About how much total time did you spend today on a break or on downtime?

_____hours _____minutes

9. During your shift when did you have breaks or downtime?

1. Only during the first half of the shift

2. Only during the second half of the shift

3. Throughout the shift

4. Other (please explain):

5. Prefer not to say

10. How much of the following did you consume during your workday?

	Amount	I do not use	Prefer not to say
Caffeinated Beverages
Cups of coffee or tea (8 oz)
Cans of soda (12 oz)
Cans of energy drinks (8 oz.; e.g., Monster, Redbull)
Bottles of 5-hour Energy (2 oz)
Nicotine
Cigarettes
Cigars, cigarillos, or little filtered cigars
Electronic cigarettes (number of puffs per day)
Cans/packages of smokeless tobacco

11. Did you use anything else to help you stay alert at work today?

_____________________________________________________________________________________

12. Job rotation is when workers alternate between tasks and jobs. Did you rotate between tasks or jobs today?

    1. Yes

    2. No

    3. Prefer not to say

13. What were your main tasks for the day?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

14. How much of your workday did you spend sitting?

Almost never Almost all the time

15. How would you describe your physical activity at work today?

    1. Mostly sedentary, no strenuous physical activity

    2. Mostly standing or walking, but no strenuous physical activity

    3. Working while standing or walking with some lifting and carrying

    4. Heavy or fast work that is physically strenuous

    5. Prefer not to say

16. Indicate how stressed you feel on the small ruler.

None As bad as it

could be

17. How many times did you remove the device from your wrist during your workday?

1. Zero

2. 1 time

3. 2 times

4. 3 or more times

5. I did not wear the device at all today

6. Prefer not to say

18. [IF 6 = “b” OR 6 = “c” OR 6 = “d”] About how many minutes in total was the device off your wrist?

_________ minutes

Public reporting burden of this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer; 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-XXXX)