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Shift Work Sleep

Page One

1. Please fill out your contact info:
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
Shift 1
Shift 2
Shift 3
6. How long are your shifts?
Space Cell First ShiftSecond ShiftThird Shift
7. What is your shift schedule?
Space Cell BeginsEnds
8. What are your shifts? If you alternate only 2 shifts, use Shift 1 and Shift 2
Space Cell BeginEnd
First Shift
Second Shift
Third Shift
9. How Many Days a Week? If you work the same shift every week, you may use just week 1.
Space Cell Week 1Week 2Week 3Week 4
First Shift
Second Shift
Third Shift
10. What is your your sleep schedule
Space Cell Sleep BeginSleep EndNap Begin Nap End
First Shift
Second Shift
Third Shift