ADULT CONSENT FORM

Time Customs and Sleep in American Indian Shift Workers

Phase 1: You will complete web-based survey about sleepiness, morningness/eveningness, time awareness, shiftwork habits, personal information and, perceived level of recent depression and factors that affect the scheduled times of daily activities and work. You will be asked to create a personal identifying name and password. These will allow you to return to the web-base survey if you are disconnected; however, access is limited to 24-hours. It will take about 40 minutes to complete the survey. For completing the survey, you will be sent a ten dollar ($10.00) gift certificate. To receive the certificate, you must (1) submit the completed web-based survey and (2) email (link is provided) personal information (name, and address) to the principal investigator. Personal information will not be connected to the survey data. The gift certificate will be mailed 5-days after receiving the email. You will also be asked to volunteer for Phase 2, the five-day real-time activity procedure.

Phase 2: For five days, (Day 1 1200 - Day 5 1200) you will wear a small (size of a wrist watch) battery operated activity monitor on your non-dominant wrist. This equipment records movement, indicating your activity/rest pattern. During a pre-arranged meeting or teleconference you will be given instructions on the measurement equipment and how to use it. You will also be asked to show or explain the equipment procedure. This part of the meeting will take approximately 60 minutes also.

You will also complete a diary (provided) of daily activities such as bed time, time of awakening, caffeine intake, meals, etc. A code (legend) is provided for marking daily activities. The activity diary information is used to verify and validate the activity monitor recording.

During the prescheduled meeting or teleconference, the activity monitoring equipment and diary completion will be discussed. You will be given an instruction booklet with specific directions about wearing the activity equipment, and also the care and removal of the equipment. The equipment should be worn continuously for five days. If the equipment is removed, you will document this in the diary. Instructions for completing the diary will be given to you both verbally and in writing.

The investigators will call you at least twice during the five days to answer any questions that you might have. At the end of the five days, you will either return the equipment and the sleep diary during a preplanned meeting or in the shipping box. A pre-paid shipping label will be supplied.

WHAT ARE THE POSSIBLE RISKS AND DISCOMFORTS YOU COULD EXPERIENCE?

Possible risks and discomforts you could experience during this study include:

Activity monitor - Due to its square edges, this equipment can cause minor irritation discomfort over bony area of the wrist. Athletic wrist guards will be provided to reduce the irritation. Wearing the equipment to bed may also be annoying for both you and your significant other.
Sleep diary - The time commitment can be inconvenient.
Questionnaire completion – “Napping at work” questions may be a concern; however, these questions are revised to “napping at home” when “napping at work” is prohibited by your employer. Additionally, personal information emailed to the principal investigator (after completing the survey) is kept separate from your individual survey. Also, some survey items asked such as recent feelings of depression may be embarrassing or disturbing.”