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Survey Templates Surveys SleepyStudentsSurvey

SleepyStudentsSurvey
It will take approximately 30 minutes to complete the questionnaire.


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You must provide a valid e-mail address to participate in this study.
You must provide your USM student ID number in order to ensure proper credit is applied to your Experimentrix account.
Please provide your name as secondary verification in order to award your credits (in case of error).
Date of Birth:
Sex:
Class standing:
Ethnic background:
At what time is your first class
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 NOON
on Monday:
on Wednesday:
on Friday:
At what time is your first class
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 NOON
on Tuesday:
on Thursday:
This is a survey of the effects of selected behaviors upon sleep. We are interested in knowing your opinion about whether any of these behaviors may influence the quality and/or quantity of sleep. For the following list of behaviors, please indicate whether you think they have a "positive" effect, a "negative" effect of "neither" effect on sleep. Please DO NOT make reference to how they influence your sleep in particular, but to the effects you think these behaviors have on people in general. Please answer all the statements by checking the appropriate box, even if you are not completely sure of the answer.
Positive Effect
Neither Effect
Negative Effect
A. Drinking alcohol in the evening.
B. Drinking coffee or other substances with caffeine after dinner.
C. Doing intense physical exercise before going to bed.
D. Taking a long nap during the day.
E. Going to bed and waking up always at the same hour.
F. Thinking about one's engagements for the next day before falling asleep.
G. Using sleep medication regularly.
H. Smoking before falling asleep.
I. Diverting one's attention and relaxing before bedtime.
J. Going to bed 2 hours later than the habitual hour.
Positive Effect
Neither Effect
Negative Effect
K. Going to bed with an empty stomach.
L. Using the bed for eating, calling on the phone, studying and other non-sleeping activities.
M. Trying to fall alseep without having a sleep sensation.
N. Studying or working intensely until late night.
O. Getting up when it is difficult to fall asleep.
P. Going to bed 2 hours earlier than the habitual hour.
Q. Going to bed immediately after eating.
R. Being worried about the impossibility of getting enough sleep.
S. Sleeping in a quiet and dark room.
T. Recovering lost sleep by sleeping for a long time.
Please indicate to what extent you agree or disagree with each statement. There is no right or wrong answer.

For each statement, mark the circle under the number which best represents your personal rating:
Strongly Disagree, Disagree, Somewhat Disagree, Somewhat Agree, Agree, Strongly Agree
Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree
1. I need 8 hours of sleep to feel refreshed and function well during the day.
2. When I don’t get a proper amount of sleep on a given night, I need to catch up on the next day by napping or on the next night by sleeping longer.
3. Because I am getting older, I need less sleep.
4. I am worried that if I go for one or two nights without sleep, I may have a nervous breakdown.
5. I am concerned that chronic insomnia may have serious consequences for my physical health.
6. By spending more time in bed, I usually get more sleep and feel better the next day.
7. When I have trouble getting to sleep, I should stay in bed and try harder.
8. I am worried that I may lose control over my abilities to sleep.
9. Because I am getting older, I should go to bed earlier in the evening.
10. After a poor night’s sleep, I know that it will interfere with my daily activities on the next day.
Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree
11. In order to be alert and function well during the day, I am better off taking a sleeping pill rather than having a poor night’s sleep.
12. When I feel irritable, depressed or anxious during the day, it is mostly because I did not sleep well the night before.
13. Because my bed partner falls asleep as soon as his or her head hit the pillow and stays asleep through the night, I should be able to do so too.
14. I feel that insomnia is basically the result of aging and there isn’t much that can be done about this problem.
15. I am sometimes afraid of dying in my sleep.
16. When I have a good night’s sleep, I know that I will have to pay for it on the following night.
17. When I sleep poorly on one night, I know it will disturb my sleep schedule for the whole week.
18. Without an adequate night’s sleep, I can hardly function the next day.
19. I can’t ever predict whether I’ll have a good or poor night’s sleep.
20. I have little ability to manage the negative consequences of disturbed sleep.
Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree
21. When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before.
22. I get overwhelmed by my thoughts at night and often feel I have no control over my racing mind.
23. I feel I can still lead a satisfactory life despite sleep difficulties.
24. I believe insomnia is essentially the result of a chemical imbalance.
25. I feel insomnia is ruining my ability to enjoy life and prevents me from doing what I want.
26. I avoid or cancel obligation (social, family, occupational) after a poor night’s sleep.
27. A “nightcap” before bedtime is a good solution to sleep problems.
28. Medication is probably the only solution to sleeplessness.
29. My sleep is getting worse all the time, and I don’t believe anyone can help.
30. It usually shows in my physical appearance when I haven’t slept well.
Please indicate to what extent you agree or disagree with each statement. There is no right or wrong answer.

For each statement, mark the circle under the number which best represents your personal rating:
Strongly Disagree, Disagree, Somewhat Disagree, Somewhat Agree, Agree, or Strongly Agree

Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly agree
1. I have a problem falling asleep.
2. I have a problem staying asleep.
3. I have a problem waking up too early in the morning.
4. I usually go to bed at the same time on the weekends as on weeknights.
5. I usually get up at the same time on the weekends as on weekdays.
6. I usually get the same amount of sleep on the weekends as on weeknights.
7. I often take intentional naps.
8. I often fall asleep unintentionally.
9. I fall asleep at inappropriate times and/or places.
10. I often exercise prior to bedtime.
Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly agree
11. I often have caffeinated beverages after dinner.
12. I often consume alcoholic beverages before bedtime.
13. I sleep better in my dorm/at home than when away.
14. I sleep better on the weekends than during the week.
15. I am concerned about the quality of my sleep.
16. I am concerned about the amount of sleep I get.
17. I am concerned that I do not get enough sleep.
18. I am concerned that I sleep too much.
19. I have to make myself go to bed.
20. I am ready to go to bed at bedtime.
Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly agree
21. Going straight to bed is not a problem for me.
22. I do not look forward to going to bed.
23. It is very difficult for me to get to bed on time.
24. I “put off” or delay going to bed.
25. When it is time to go to sleep I am quiet.
26. When it is time to go to sleep I feel calm.
27. When it is time to go to sleep I feel drowsey.
28. When it is time to go to sleep I have trouble settling down.
29. When it is time to go to sleep I lie down, but then get up and come out of the bedroom.
30. I am slow-to-start in the mornings.
Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly agree
31. I find it difficult to get out of bed in the mornings.
Please indicate to what extent the following things have occurred during the past month:

Never, Seldom, Sometimes, Often, Frequently, Always

Never
Seldom
Sometimes
Often
Frequently
Always
32. During the day I took a nap lasting more than an hour.
33. During the day I played or exercised for more than 20 minutes.
34. After 6:00 in the evening, I had drinks with caffeine (for example: soda, iced tea, coffee, energy drinks).
35. After 6:00 in the evening, I smoked or chewed tobacco.
36. After 6:00 in the evening, I drank beer (or other drinks with alcohol).
37. During the hour before I went to bed, I did things that make me feel calm or relaxed (for example: taking a hot bath/shower, listening to soft music).
38. During the hour before I went to bed, things happened that made me feel strong emotions (for example: sadness, anger, excitement).
39. During the hour before I went to bed I was very active (for example: playing sports, running).
40. During the hour before I went to bed I did things that made me feel very awake (for example: playing video games, watching TV, talking on the telephone).
41. During the hour before I went to bed I drank more than 4 glasses of water (or some other liquid).
Never
Seldom
Sometimes
Often
Frequently
Always
42. I went to bed and did things that kept me wake (for example: watching TV, reading).
43. I went to bed and thought about things I needed to do.
44. I went to bed feeling upset.
45. I went to bed and replayed the day’s events over and over in my mind.
46. I went to bed and worried about things happening at home or at school.
47. I went to bed with a stomachache.
48. I went to bed hungry.
49. I went to bed thirsty.
50. I fell asleep while listening to loud music.
51. I fell asleep while watching TV.
Never
Seldom
Sometimes
Often
Frequently
Always
52. I fell asleep in a brightly lit room (for example: the overhead light was on).
53. I fell asleep in one place and then moved to another place during the night.
54. I fell asleep in a room that felt too hot or too cold.
55. I slept alone.
56. I slept all or part of the night with someone else (for example, roommate, spouse/significant other, sibling).
57. I slept in a home/room where someone smokes cigarettes, cigars, or a pipe.
58. I got too little sleep.
59. I used a bedtime routine (for example: bathing, brushing teeth, reading).
60. I used my bed for things other than sleep (for example: talking on the telephone, watching TV, playing video games, doing homework).
61. I checked my clock several times during the night.
Never
Seldom
Sometimes
Often
Frequently
Always
62. During the school week, I stayed up more than an hour past my usual weeknight bedtime.
63. During the school week, I “slept in” more than an hour past my usual weekday wake time.
64. On the weekends, I stayed up more than an hour past my usual weekend bedtime.
65. On the weekends, I “slept in” more than an hour past my usual weekend wake time.
66. When it was time to go to bed, I had other things to do.
67. When it was time to go to bed, I went straight to bed.
68. When it was time to go to bed, I wanted to stay up and do other things (for example: read, work, watch TV).
69. When it was time to go to bed, I was struggling to stay awake.
70. When it was time to go to sleep (“lights out”), I was quiet.
71. When it was time to go to sleep (“lights out”), I felt calm.
Never
Seldom
Sometimes
Often
Frequently
Always
72. When it was time to go to sleep (“lights out”), I felt drowsy.
73. When it was time to go to sleep (“lights out”), I had trouble settling down.
74. When it was time to go to sleep (“lights out”), I laid down, but then got up and left the bedroom.
75. I had trouble going to sleep.
76. I needed help getting to sleep (for example: medication, alcohol, music, TV).
77. I fell asleep quickly.
78. During the night, I tossed and turned in the bed.
79. During the night I was very restless.
80. During the night I moaned, groaned or talked in my sleep.
81. During the night I kicked off the covers.
Never
Seldom
Sometimes
Often
Frequently
Always
82. During the night I aroused, but did not fully awaken.
83. During the night I awakened more than once.
84. I slept soundly through the night.
85. After waking up during the night, I had trouble going back to sleep.
86. Ater waking up during the night, I had difficulty getting comfortable.
87. After waking up during the night, I left the bedroom.
88. After waking up during the night, I needed help to get back to sleep (for example, medication, TV, music).
89. After waking up during the night I felt unsettled.
90. After waking up during the night I used the bathroom.
91. After waking up during the night I ate or drank.
Never
Seldom
Sometimes
Often
Frequently
Always
92. After waking up during the night I went right back to sleep.
93. In the morning, I woke up without any help (for example: alarm clock, another person).
94. In the morning, I woke up feeling ready to begin the day.
95. In the morning, I woke up rested and alert.
96. In the morning, I woke up feeling “grumpy.”
97. In the morning, I just couldn’t “get going.”
My usual weeknight bedtime is
My usual weekday wake time is
My usual weekend bedtime is
My usual weekend wake time is

Less than 15 min.
15 to 30 min.
30 to 45 min.
45 to 60 min.
60 to 75 min.
more than 75 min.
102. How long do you usually “put off” or delay going to bed?

Less than 15 min.
15 to 30 min.
more than 30 min.
103. How long does it usually take you to fall asleep after “lights out"?

Never
1 to 2 times
3 or more times
104. How often do you usually wake up during the night?

Less than 15 min.
15 to 30 min.
More than 30 min.
105. How long does it usually take you to go back to sleep after waking during the night?

Less than 5 min.
5 to 15 min.
More than 15 min.
106. How long does it take you to feel completely awake in the morning?
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