PARTICIPANT NUMBER:

Survey Gender: Male

Female

22-25

1. What is your age? Less than 18

18- 21

More than 25

Graduate

2. What is your year in college: Freshmen/1st Sophomore/ 2nd

Junior/ 3rd

Senior/ 4th

3. How many hours did you sleep last night? Less than 3

No

3-4

5-6

7-8

9-10

More than 10

4. (a) Do you suffer from any sleep disorder (insomnia, sleep apnea, etc)? Yes

4. (b) If so which sleep disorder? ______________ 5. Do you have difficulty falling asleep? Yes

No

30- 1hr

6. How long does it take you to fall asleep? Less than 30 minutes

More than an hour

7. (a) Do you use any sleep aids to help you fall asleep or stay asleep? Yes

No

Over-the-counter

7. (b) If you do take sleeping aids, which are they? Prescribed

7. (c) Did you take any sleeping aids last night? Yes

No

8. Did you nap yesterday, before going to bed? Yes No

9. Did you nap/sleep today after waking(example: while commuting, on the bus, train etc.)? Yes No

QUESTIONS CONTINUE ON REVERSE

10. Did you have breakfast today? Yes

No

11. (a) Did you have coffee today? Yes No

11. (b) If so, how many cups? 1

More than 4

QUESTIONS CONTINUE ON REVERSE