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Shift Work Sleep

Page One

1. Please fill out your contact info:

First Name

Last Name

Title

Company Name

Street Address

Apt/Suite/Office

City

State

Postal Code

Country

Email Address

Phone Number

Fax Number

Mobile Phone

Website URL

2. How long have you been working shifts?

3. Does your shift work involve more than 1 job at the present time?

5. What is the sequence of your shifts?

	Week 1	Week 1	Week 2	Week 2	Week 3	Week 4
	Week 1	Week 1	Week 2	Week 2	Week 3	Week 4	Shift 1	Week 1	Week 1	Week 2	Week 2	Week 3	Week 4
Shift 2	Week 1	Week 1	Week 2	Week 2	Week 3	Week 4
Shift 3	Week 1	Week 1	Week 2	Week 2	Week 3	Week 4

6. How long are your shifts?

Space Cell	First Shift	Second Shift	Third Shift
Shift	First Shift	Second Shift	Third Shift

7. What is your shift schedule?

Space Cell	Begins	Ends
First	Begins	Ends
Second	Begins	Ends
Third	Begins	Ends

8. What are your shifts? If you alternate only 2 shifts, use Shift 1 and Shift 2

Space Cell	Begin	End
First Shift	Begin	End
Second Shift	Begin	End
Third Shift	Begin	End

9. How Many Days a Week? If you work the same shift every week, you may use just week 1.

Space Cell	Week 1	Week 2	Week 3	Week 4
First Shift	Week 1	Week 2	Week 3	Week 4
Second Shift	Week 1	Week 2	Week 3	Week 4
Third Shift	Week 1	Week 2	Week 3	Week 4

10. What is your your sleep schedule

Space Cell	Sleep Begin	Sleep End	Nap Begin	Nap End
First Shift	Sleep Begin	Sleep End	Nap Begin	Nap End
Second Shift	Sleep Begin	Sleep End	Nap Begin	Nap End
Third Shift	Sleep Begin	Sleep End	Nap Begin	Nap End