SURVEY TALLY FORM

TITLE: Sleeping Pattern and Academic Performance of Science, Technology,

and Engineering Students of Llanera National High School:
A Correlational Study

Distribution of Respondents According to Section

SECTION NUMBER OF STUDENTS
8-STE-Earth
8-Mars
8-Jupiter
8-Venus
8-Mercury
TOTAL

Distribution of Respondents According to Gender

GENDER NUMBER OF STUDENTS
Male
Female
TOTAL

Distribution of Respondents According to Age

AGE NUMBER OF STUDENTS
11-12
13-14
15-16
TOTAL

Pittsburgh Sleep Quality Index

RATINGS:
1 – >7 hours 1 – <15 minutes 1 – Not during the past month 1 – Very Good
2 – 6-7 hours 2 – 16-30 minutes 2 – Less than once a week 2 – Fairly Good
3 – 5-6 hours 3 – 31-60 minutes 3 – Once or twice a week 3 – Fairly Bad
4 – <5 hours 4 – >60 minutes 4 – Three or more times a week 4 – Very Bad
1 – No problem at all
2 – Only a very slight problem
3 – Somewhat of a problem
4 – A very big problem
QUESTION >7 6-7 5-6 <5 TOTAL
HOURS HOURS HOURS HOURS
1. During the
past month,
what time
have you
usually gone
to bed at
night?
<15 16-30 31-60 >60 TOTAL
MINUTES MINUTES MINUTES MINUTES
2. During the
past month,
how long (in
minutes) has
it usually
taken you
fall asleep
each night?
>7 6-7 5-6 <5 TOTAL
HOURS HOURS HOURS HOURS
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 NOT LESS ONCE OR THREE TOTAL
past month, DURING THAN TWICE A OR MORE
how often THE PAST ONCE A WEEK TIMES A
have you had MONTH WEEK WEEK
trouble
sleeping
because…

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
breath
comforta
bly
e. Cough or
snore
loudly
f. Feel too
cold
g. Feel too
hot
h. Had bad
dreams
i. Have
pain
j. Other
reason(s),
please
describe
_______
_____
6. How often
 during the
past month
have you had
trouble
sleeping
because of
this?
VERY FAIRLY FAIRLY BAD VERY TOTAL
GOOD GOOD BAD
7. During the
past month,
how would
you rate your
sleep quality
overall?
NOT LESS ONCE OR THREE TOTAL
DURING THAN TWICE A OR MORE
THE PAST ONCE A WEEK TIMES A
MONTH WEEK WEEK
8. During the
past month,
how often
have you
taken
medicine to
help you
sleep
(prescribed
or “over the
counter”)?
9. 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 TOTAL
PROBLEM VERY A PROBLEM BIG
AT ALL SLIGHT PROBLEM
PROBLEM
 10. During the
past month,
how much of
a problem
has it been
for you to
keep enough
enthusiasm
to get things
done?
NO BED PARTNER PARTNER IN PARTNER TOTAL
PARTNER /ROOM THE SAME IN SAME
/ROOM MATE IN ROOM BUT BED
MATE OTHER NOT THE
ROOM SAME BED
11. Do you have
a bed partner
or room
mate?

12. If you have a NOT LESS ONCE OR THREE TOTAL

room mate or DURING THAN TWICE A OR MORE
bed partner, THE PAST ONCE A WEEK TIMES A
ask him/her MONTH WEEK WEEK
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
disorientatio
n or
confusion
during sleep
e. Other
restlessness
while you
 sleep; please
describe
__________
___

Academic Performance
RATINGS:
1 – Below 75 (Did not meet expectations)
2 – 75-79 (Fairly satisfactory)
3 – 80-84 (Satisfactory)
4 – 85-89 (Very satisfactory)
5 – 90-100 (Outstanding)
90-100 85-89 80-84 75-79 BELOW TOTAL
75
GENERAL
WEIGHTED
AVERAGE
DURING 2ND
QUARTER