Sleep Deprivation Survey + Sample Questionnaire Template

The sleep deprivation survey is a questionnaire designed to collect feedback from a student respondent about their sleep habits and the situations in which they feel sleepy. This sample survey template also collects data on other parameters like GPA to understand from each student, the causes of sleepiness and collect feedback on the aspects that can be introduced to reduce the negative effects of sleep deprivation. This in-depth survey consists of various survey questions that profiles a student that is part of a clinical site and the reasons that cause sleeplessness as well as the circumstances under which they feel sleepy.

How likely are you to doze off or fall asleep while
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
While sitting and reading
While watching TV
When sitting, inactive in a public place (e.g., a theater or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
While sitting and talking to someone
While sitting quietly after a lunch without alcohol
When in a car, while stopped for a few minutes in traffic
How many hours of sleep per night do you average?
What are the numbers of hours you spend per week at your clinical site or workplace?
What are the numbers of hours per week you spend studying, at lectures/meetings, etc.?
How many days of vacation does your program allow?
What is your current GPA?
How does sleepiness affect your clinical and didactic performance as a nurse anesthesia student?
If you are experiencing sleepiness, what do you feel are the causes?
What can be introduced into your nurse anesthesia program to improve the negative effects of sleep deprivation in your clinical and didactic experiences?

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