Informed Consent
Dear Participant,
I am a BS Applied Psychology student conducting a research study. Your participation in this
study is completely voluntary. All information provided by you will remain strictly confidential
and will be used only for academic purposes. There are no known risks involved in participating
in this study, and you may withdraw from the study at any time without any penalty. By
completing this questionnaire, you are indicating your consent to participate in this research.
Thank you for your cooperation.
Participant’s Signature: _______________________
Date: _______________________
Demographic Information
1 Name __________________________
2 Gender ☐ Male ☐ Female
3 Age __________ years
4 Current Semester __________
5 Department __________________________
6 Residence ☐ Village ☐ City
7 Marital Status ☐ Single ☐ Married
CGPA / Academic ☐ Below 2.0 ☐ 2.0–2.49 ☐ 2.5–2.99 ☐ 3.0–3.49 ☐ 3.5–
8
Performance 4.0
Assesment No 1
Instructions: The following questions relate to your usual sleep habits during the past month
only. Your answers should indicate the most accurate reply for the majority of days and nights
in the past month. Please answer all questions.
1. During the past month, what time have you usually gone to bed at night?
___________________
2. During the past month, how long (in minutes) has it usually taken you to fall asleep each
night? __________
3. During the past month, what time have you usually gotten up in the morning?
___________________
4. During the past month, how many hours of actual sleep did you get at night? (This may
be different than the number of hours you spent in bed.) ___________________
5. During the past month, how often have Not during Less than Once or Three or more
you had
trouble sleeping because you… the past once a twice a times a week
month week week
a. Cannot get to sleep within 30 minutes
b. Wake up in the middle of the night or
early morning
c. Have to get up to use the bathroom
d. Cannot breathe comfortably
e. Cough or snore loudly
f. Feel too cold
g. Feel too hot
h. Have bad dreams
i. Have pain
j. Other reason(s), please describe:
6. During the past month, how often have
you taken medicine to help you sleep
(prescribed or “over the counter”)?
7. During the past month, how often have
you had trouble staying awake while
driving, eating meals, or engaging in social
activity?
No Only a Somewhat A very big
problem very slight of a problem
at all problem problem
8. During the past month, how much of a
problem has it been for you to keep up
enough enthusiasm to get things done?
Very Fairly Fairly Very
good good bad bad
9. During the past month, how would you
rate your sleep quality overall?
No bed Partner/room Partner in Partner in
partner or mate in other same room but same bed
room mate room not same bed
10. Do you have a bed partner or room mate?
Not during Less than Once or twice Three or
the past once a week a week more times a
month week
If you have a room mate or bed partner, ask
him/her how often in the past month you have
had:
a. Loud snoring
b. Long pauses between breaths while asleep
c. Legs twitching or jerking while you sleep
d. Episodes of disorientation or confusion
during sleep
e. Other restlessness while you sleep, please
describe:
Assesment No 2
Instructions:
The questions in this scale ask you about your feelings and thoughts during the last
month. In each case, you will be asked to indicate how often you felt or thought a certain
[Link] the last month, how often have you...
Never Almost Never Sometimes Fairly Often Very Often
been upset because of something that
happened unexpectedly? 0 1 2 3 4
1 felt that you were unable to control the
important things in your life? 0 1 2 3 4
2
felt nervous and "stressed"? 0 1 2 3 4
3
felt confident about your ability to handle your
personal problems? 4 3 2 1 0
4
5 felt that things were going your way? 4 3 2 1 0
found that you could not cope with all the things
6 0 1 2 3 4
that you had to do?
7
been able to control irritations in your life? 4 3 2 1 0
8
felt that you were on top of things? 4 3 2 1 0
9
been angered because of things that were
0 1 2 3 4
10 outside of your control?
felt difficulties were piling up so high that you
could not overcome them? 0 1 2 3 4