.

,-A267 7461

SLEEP MANAGEMENT USER'S GUIDE

FOR SPECIAL OPERA TIONS PERSONNEL

DTIC
ELECTE
AUGJ,0 19931

P. Naitoh

T. L. Kelly

II

Report No. 92-28

93-18338
Approve(d for public release distributiol) knlilililiitid

NAVAL HEALTH RESEARCH CENTER

P.O_ BOX 85122
SAN DIEGO, CALIFORNIA 92186-5122

NAVAL MEDICAL RESEARCH AND DEVELOPMENT COMMAND

BETHESDA, MARYLAND
 Sleep Management User's Guide
for Special Operations Personnel

Paul Naitoh
Tamein Lisa Kelly

iRaval Health Research Center

Physiological Performance and
Operational Medicine Department
Special operations Division
P.O. Box 85122-_ __

San Diego, CA 92186-5122 (Cll! o

NTIS CR&

AvdPCIdld

o'rIC QUALITY IN'SPECT~ED 3

Report No. 92-28, slupported by the Naval Medical Research and Development
Command, Department of the Navy, under work unit 62233N MM33P30.002-6005. The
views expresoed iLn thio article are those of the authors and do not reflect the
official policy or position of the Department of the Navy, the D~rep3a-- nent of
Defense, or the U.S. Government. Approved for public release; distribu..'ion is
unlimited.
 Table of Contents

Page

SUMMARY ............................... ................................ 3

SLEEP MANAGERS' QUICK REFERENCE --- KEY FACTS AND RECOMMENDATIONS.... 4
SECTION 1 BACKGROUND AND PURPOSE .................. ................... 7
SECTION 2 SLEEP AND SLEEP DEPRIVATION ............... ................ 8
SECTION 3 SUSTAINED OPERATIONS AND SLEEP MANAGEMENT ..... ......... 11
SECTION 4 PERFORMANCE DEGRADATION ............... .................. 14
SECTION 5 SLEEP MANAGEMENT IN FIELD TRAINING ........ ............. 19
SECTION 6 SLEEP TRAINING .................... ....................... 25
SECTION 7 DRUGS .......................... ........................... 26
SECTION 8 THE EFFECTS OF LIGHT ............... .................... 29
SECTION 9 CONCLUSIONS/SUMMARY ................. .................... 30

APPENDICES

APPENDIX 1 - SLEEP LOG ....................... ........................ A-I

APPENDIX 2 - NAVHLIHRSCHCEN MOOD SCALE ............. ................ A-3
APPENDIX 3 - PLUS 7 TASK TABLE ................. .................... A-5
APPENDIX 4 - SLEEP QUESTIONNAIRE ................. ................... A--7
APPENDIX 5 - MISSION EXAMPLE ................... ..................... A-i1

2
 Summary

Sleep management is the study of sleep, its effects on personnel, and methods to
satisfy sleep requirements under demanding work schedules. Sleep logistics is
the application of sleep management to military operations. The objective of
sleep logistics is to ensure that fighting men and women at all levels obtain
sufficient sleep to maintain combat effectiveness. In the past, major battles
usually occurred during the day due to the limitations of night visibility and
unreliable equipment (which inhibit target detection and classification
capabilities). Technological advances diminish these obstacles, such that combat
can occur both day and night. Sleep loss can result, making sleep logistics an
important issue. Special warfare missions frequently involve night work and
arduous o'>_rational schedules. This user's guide explains selected sleep
management techniques for use during military operations, with particular
emphasis on special operations missions. The guide will assist field commanders
in using sleep logistics to prevent compromise of mission accomplishment due to
sleep deprivation. It also provides basic information about the need for sleep
and consequences to behavior and mood when that need goes unsatisfied.
Additionally, the guide provides techniques for assessing severity of sleep debt
and compensating for its ill effects. The maost important steps to be taken for
effective sleep management are to: a) prepare a work/rest-sleep plan to meet
sleep needs; and b) employ self-diagnostic techniques to detect and compensate
for the effects of sleep debt. Key facts and recommendations for sleep
management are listed, along with countermeasures to the effects of sleep loss.

3
 SLEEP MANAGERS' QUICK REFERENCF -- KEY FACTS AND RECOMMENDATIONS

Degrading effects of sleep loss on performance, moous, and

motivation to work are felt most strongly during the daily circadian
trough, as detined by body temperature. The circadian trough occurs
between 0200 and 0600 of the time zone to which the body is adapted.
There is a significant loss of performance efficiency when an
operation demands a longer-than-24-hour continuous work episode
(CWE). After a CWE of 36 hours, target detection is 70% and
decoding is 50% of baseline.
Uninteresting and complex tasks are more seriously affected by sleep
loss than interesting and/or simple tasks.
Critical but routine tasks are often skipped, since sleep loss
reduces overall willingness to respond.
Physical work feels much heavier with sleep loss because of
exaggerated perceptions of physical exertion.
Short-term memory is seriously affected. Poor short-term memory and
lapses in attention work against effective communication. Sleep
loss can cause a listener to forget what was recently said in a
conversation. A listener may fill the information gap by
inaccurately restruccuring the conversation.
The ability to initiate action decreases with increasing sleep debt.
This decrease in initiative includes all interactions among team
members.
Sleep-deprived individuals tend to overestimate their ability to
perform tasks. They lose insight as to how well they are performing
their assigned tasks.
• Sleep loss causes deterioration of personal hygiene.
* Often, higher ranking personnel are more likely to go without sleep
because they feel their duties are the most critical and cannot be
fulfilled by others. Paradoxically, this sense of duty can result
in performance impairment, compromising the very goals they sought
to achieve by denying themselves sleep.
Sleep loss can be measured by the use of sleep logs to quantitate
the amount and timing of sleep and by the use of a mood scale and
the plus 7 task to quantitate the impact of sleep loss.
Uninterrupted sleep is more restorative. Avoid interruptions (e.g.,
employ bladder prior to attempting to sleep).
Optimize your circadian rhythms by following a regular schedule
every day.
Sloep can bo
* improved by: following a regular nighttime routine,
avoiding caffeine tor several hours before bed, avoiding excessive
 alcohol, avoiding tobacco, not becoming dependent on sleeping
medications, using muscle relaxation techniques, developing a
positive attitude about sleep and doing your worrying somewhere
other than bed.

Suggestions to limit sleep deprivation during an operation are listed

below:
* Resting i! not sleeping. It is the amount of actual sleep that
counts.
* Partial sleep deprivation over multiple days has a cumulative
effect.
* We may be able to store up a little extra sleep taken ahead of time.
certainly, do not begin a prolonged operation already sleep-
deprived. However, sleep periods of over 10 hours should be
avoided.
* Taking naps can interfere with nighttime sleep. However, naps are
beneficial when insufficient sleep is othierwise not available.
* Physical signs of serious sleep loss are: vacant stare, "glazed"
eyes; pale skin; body sways upon standing, sudden dropping of chin
upon sitting; intermittent lose of hand grip strength; walking into
obstacles and ditches; poor personal hygiene; very slow heart rate;
loss of interest in surroundings; slurred speech.
* Train to be an effective sleeper and learn techniques to help induce
sleep under unusual and stressful conditions.
• Get as much sleep as possible before an operation. Avoid incurring
a sleep debt before the start of an operation when sleep may be
limited.
* Try to sleep at least four to five hours in a single, unbroken
period each 24 hours. This amount of sleep should be adequate to
maintain maximum performance for a month or longer.
* During military operations where sleep is limited, use every
opportunity to take naps (preferably greater than 20 minutes).
Napping is usually beneficial in maintaining task performance.
However, be aware that awakening from naps may be accompanied by
sleep inertia. Allow enough time (five to ten minutes) to overcome
this before beginning activities.
S IUse diagnostic aids, such as a sleep/activity diary, a mood scale,
and the Plus / Task, to obtain a realistic measure of sleep debt
severity.

5
If sleep deprivation cannot be avoided, be aware of and plan for its
effects:
* Know the individual sleep loss tolerances of the personnel under
your command.
* Realize that self-observation deteriorates with sleep loss. Combat
unit members may be unaware of significant impairment, so
institution of countermeasures should be based on the known degree
of sleep deprivation, not on whether people feel they need them.
* Allow more time than usual for completion of all activities.
* Assign the most sleep deprived individuals to self-paced,
interesting, and/or easy jobs.
• Critical activities may require increased numbers of personnel.
* Effective communication will require increased effort. Always
confirm orders by repeating them aloud, and as sleep loss
progresses, write orders down.
* Be aware of circadian rhythms. All sleep loss effects will be worst
during the early morning hours (of the time zone to which you are
adapted).
* Physical activity may temporarily counteract sleepiness, but
activities will seem more difficult than usual, and sleepiness and
fatigue will be increased afterwards.
* Sleep may be stored to some extent, thus longer than usual sleep
periods (but less than ten hours) may be beneficial.
* Early bedtimes produce better results than later rising to increase
sleep period.

6
 SECTION 1 BACKGROUND AND PURPOSE
This user's guide explains the principals and applications ot sleep
management.

1.0 Background and Problems

Sleep management for military personnel (sleep logistics) was developed
roughly 30 years ago by Lieutenant Colonel Harold Williams of the Walter Reed
Army Institute of Research. Sleep logistics, which includes work/rest-sleep
planning, is of serious concern when personnel must work without sleep for more
than 24 hours under conditions of decreased or disrupted sleep, particularly at
night.
All levels of military personnel may be subjected to such stressful work
schedules: those on the front line, those involved in resupplying the front
line, and those participating in special missions. Historically, major battles
were often limited to daylight hours because of poor night visibility and
unreliable equipment. With improved technology, these problems have decreased;
as a result, personnel may be required to fight both day and night.
Behavioral problems associated with sleep loss during military operations
are well documented. George E. Marshall's observation during the Normandy
Operation in World War II accurately describes these problems: disorientation,
overwhelming sleepiness, and inability to give and receive orders due to
uncontrollable lapses in attention and poor memory. Sleep logistics has been
proposed as a means of preventing these problems by way of work/rest-sleep
planning.

1.1 Purpose
The purpose of this user's guide is to provide basic information for field
comunanders about the need for sleep and consequences to behavior and mood when
that need goes unsatisfied. The user's guide outlines the best available
techniques for preventing excessive sleep loss, determining the severity of
sleep debt, and countering the ill effects of sleep loss so that military
objectives can be achieved. This user's guide is based upon two decades of sleep
research conducted by the Naval Health Research Center (NAVHLTHRSCHCEN), San
Diego, California.

7
 SECTION 2 SLEEP AND SLEEP DEPRIVATION
Section 2 describes the normal sleep/wake cycle of human beings and reviews
the effects of various disruptions to this cycle.

2.0 Circadian Rhythms

Humans evolved as diurnal creatures. That is, people are designed to be
active during the day &nd to sleep for a continuous seven- to eight-hour period

each nint. Every aspect of each individual (physical and mental performance,
mood, body temperature, blood pressure, pulse, etc.) shows a characteristic
variation over a 24-hour cycle. These 24-hour variations are called "circadian
rhythms."
Generally, a person will work most effectively in the afternoon and evening
(1400 to 2000), although memory processes may peak somewhat earlier; this is
called the "circadian peak." The time of least effective work is in the early
morning hours (0200 to 0600), or the "circadian trough." Figure 1 represents
speed and performance accuracy for a mental task over two days and nights without
sleep. The subjects were Basic Underwater Demolition/Sea, Air, Land (BUD/SEAL)
students who had successfully completed Phase 1 training. The physical
characteristics of this population closely resemble those of SEALs (Beckett et
al., 1989). For accuracy (percent correct), higher numbers represent better
performance. Speed (reaction time) is presented as the inverse (1/sec), so that
higher numbers represent better performance for this measure as well.

FIGURE 1

The data in Figure 1 illustrate two important points. First, performance

varies across the day, with the worst performances occurring during the early
morning hours (the usual sleep period). As subjects continue to work into the
morning and afternoon of the second and third day, perforr~iances improves relative
to the preceding night, despite the fact that sleep deprivation continues to
progress. Second, performance deteriorates as sleep deprivation continues. When
performance at the same time on the second day is compared to that of the first
day, the second-day performance is always worse. The worst performance occurs
during the second late-night work period, when detrimental effects of working
during the usual sleep period are compounded by effects of accumulated sleep
deprivation. In summary, people work best during daytime hours and w-•st late
at night (between 0200 and 0600); both daytime and nighttime performance can be
degraded when preceded by sleep deprivation.

S{8
 Percent Correct
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1730-
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Speed (1/sec)

8A
2. 1 S leep___pr ivat ion
Sleep deprivation can be totol or partial. Total sleep deprivation
involves n1o sleep for 24 hours or more. In military operations, this can occur
during prolonged, intense operations. Often, higher rankinq personnel are more
likely to go without sleep because they feel their duties ac'e the most critical
and cannot be fulfilled by others. Par.adoxically, this sense of duty can result
inl perfor-mance impairment, compromising the very goals they sought to achieve by
denying themselves sleep.
Partial sleep deprivation involves anything less than the "usual" amount
of sleep a given individual requires. Sleep requirements vary from person to
person, but the average ideal sleep period is seven to eight hours each night.
Must people can] restrict sleep to four to five hours per night for weeks (or even
mon~ths) without major effects on cognitive, physical, and motor performance,
although mood and motivation may suffer. As sleep is cut back beyond this,
performance usually suffers. With special prolonged training, seone people have
learned to maintain performance on only three hours of sleep a day, divided into
several nap periods. Whether or not this can be accomplished without prolonged
traini~ng has not yet been fully researched.
Sleep deprivation is cumulative. A little deprivation over many days ran
add up. A detailed description of signs and symptoms of sleep depr.ivation is
presented in Section 4.0.

2.2 Np
Circadian rhythms apply to sleep as well as performance. Just as work
per-formance is wor:st at night, sleep is least effective during the day. That is,
a given amount of sleep taken during the day will probably be less recuperative•
than the same amount during the night. Sleep is most effective when taken in a
single, continuous period rather than manly short naps; however, nap sleep can be
valuable. When total sleep deprivation is reduced to part-ial sleep deprivation
vi~a naps, the [ike.]. ihooo of improving performance, and therefore operations
succ~ess, is increased. There i~s evidence that people can, learn to nap
effectively with pr'actice. It is important to be aware that "resting" is not the
same as sleeping. Onl~y act~ual sleep can satisfy the body's need for sleep and
r~everse thle effects of sleep deprivation. Merely resting, even in bed with eyes
c:]osed, does nut •Lu I I.] the riced for sleep.

2.3 Sleep_ Inire:t i. :

In daily rout ine , most peaopl.e do not: per form cr it ical opertat~ions upon
awikeni ng . The body and mind ar'e aiccustomed to awakening gradual ly, eas ingj into
thie day s act ivities. When people are requ Lred to perform act~ivities immediately
upon aiwa ken inrg, there i.s of tei a ler iod of con fusion, sI.uqggi shnes s, and 1aw'k of
cuoordilnat.ioni. "'fh is po.• t--sleep st. ate, usua Ily last i.ng ab~out: tivye mi nutesr, i s
called "sleep inertia." Currently, no convincing evidence exists to indicate
that sleep inertia worsens at any particular point in the circadian cycle.
Therefore, sleep inertia should not impact on the time of day a person sleeps.
However, individuals who have already accumulated a degree of sleep deprivation

may show more severe or prolonged sleep inertia. Also, unusually pr'olonged sleep
periods (more than 10 hours) may be followed by a period of severe sleep inertia.
Unlike most civilian environments, combat may requirte participation in
complex and important behaviors immediately upon awakening. The possibility of
sleep inertia mast be taken into account in deciding when and for how long
personnel may sleep. It must also be a determinant in assigning activities to
personnel who have just awakened (awake less than five to ten minutes).

2.4 Jet Lag

The circadian rhythm of the sleep/wake cycle attunes to the part of the
world where a person lives. When a person travels to a new time zone, his or her
Lnternai clock is out of synchronization with local time. For example, if a
person travels east from Los Angeles to Germany, the body clock (still on home
base time) will be nine hours out of synchronization with German time. Working
between 1100 and 1500 German time (normally an ideal time to work) means the body
and mind are working at 0200 to 0600 Los Angeles time (the circadian trough
period and the worst time to work). Under these circumstances, optimal
performances and moods cannot be expected. Adjustment to a new time zone is
gradual, requiring a week or two for large shifts. Until adjustment is complete,
signs and symptoms of jet lag will persist. During a period of jet lag, a
person may experience low energy, bleepiness during the day, irritability, and
moodiness. Reaction time and other aspects of performance may not measure up to
usual levels. Headaches, intestinal upset, arnd difficulty in sleeping are likely
to occur. The latter caii, in turn, further aggravate jet lag symptomr.

10
 SECTION 3 SUSTAINED OPERATIONS AND SLEEP MANAGEMENT
Section 3 defines sustained operations and aleep management.

3.0 0perational Relevance

Military operations can be prolonged. Short military operations may be
closely spaced, with little recovw!y time in-between. Participants in one
mission or operation may have to assist in subsequent missions or operations,
thus limiting their opportunity for rest and recovery. Two terms used when
discussing such situations are "continuous work episodes" (CWE) and "sustained
operations" (S[,SOPS). A CWE is a time period during which one works without
pause for rest/sleep. Sustained operations contain one or more CWEs, and last
for more than 24 hours. Three primary factors have limited the duration of CWEs
in the past: a) limited vision at night; b) equipment unreliability; and c)
limited endurance. With improved technology, the duration of CWEs is determined
primarily by endurance, which is limited primarily by the need for sleep. In
otner words, the duration of SUSOPS is determined by the combat unit's endurance,
not by weapon or target reliability, weather, or darkness.
Along with one or more CWEs, most prolonged operations include relatively
quiet periods. Various levels of intensity characterize a battlefield
environment. Distinct phases include movement to contact enemy forces, fighting,
consolidation, regrouping, and resupply. Periods of intense, continuous
fighting, with no chance for rest/sleep, are CWEs. Even on the front line,
where relatively quiet periods with opportunities for short periods of rest can
occur, one must always be ready to quickly resume fighting. A series of closely-
spaced missions with intensive pre-mission planning and pi ýparation requirements
can approach a SUSOPS-type situation.

3.1 Sleep Management

Sleep management pertains to techniques for optimizing sleep for those who
must work under demanding shifts or continuous schedules. Its purpose i.,
prevention of and compensation for deteriorating performance, moods, and
motivation caused by lack of sleep. Researchers in tho area of sleep management
are investigating new psychological, physiological, pharmacological, nutritional,
and biochemical methods to remedy and counteract the effects of sleep loss.
Sleep logistics is the application of sleep management to military
operatLons -- ustablishing and requiring compliance to a work/rest-sleep
schedule. Sleep logistics plans times and places for sleep in operations or
closely-spaced missions lasting a total of 24 hours or more. The objective of
sleep logistics is straightforward: fighting men and women, at all levels, must
have sufficient periods of quality sleep. They must be able to recuperate from
the fatigue and stress of CWEs and maintain, both as individuals and as a
fighting unit, combat effectiveness during SUSOPS and other stressful schedules.

11
3.2 Sleep Manaaement Recommendations
Sleep management provides ways to reduce sleepiness and the accumulation
of fatigue during CWEs. Using mission scenario operatiur. guidelines, periods of
available sleep and total number of possible sleep hours must be determined.
Since changes in operational requirements are inevitable, it is recommended that
several work/rest-sleep plans be prepared for all phases of an operation; the
best plan can be adopted for altered requirements.
Predeployment Phase. Many people tend to live under conditions of mild
sleep deprivation, never getting quite as much sleep as they really need. Data
suggest sleep may be stored to some extent. Thus, the week before a period of
intense work is not the time for personnel to put in late nights, either for work
or for fun. Instead, longer-than-usual sleep periods (no more than 10 hours)
would be beneficial. Early bedtimes produce better results than later rising
t imes.
Also, personnel must become familiar with the surroundings and conditions
under which they will sleep. For example, some people may have to sleep in
chemical-protective garments. If sleep in such unusual conditions is anticipated
in forthcoming operations, sleep management requires that personnel practice
sleeping under these conditions during the predeployment phase. Similarly, good
sleep managers will try out anticipated work/rest-sleep schedules before an
operation. For example, if personnel will be working predominantly at night
during a mission, it may be helpful to convert to a night-work/day-slaep cycle
(relative to your destination time zone) for a period preceding deployment.
Deployment Phase. During the deployment phase, sleep quality can be
reduced by time pressures, traveling in uncomfortable vehicles, and changes in
time zone and climate. Preplanned work/rest-sleep schedules should be adopted
and followed as closely as possible so that combat unit members may be fully
combat effective.
Pre-combat Phase. As discussed in Sections 2.0 and 2.4, the body has a
circadian rhythm associated with the time zone to which it is adapted. If
deployment involves rapid transfer across more than one or two time zones, some
degree of jet lag will occur. When there is a week or more delay between combat
zone arrival and actual combat, personnel cart adjust to the new time zone.
However, when there is no delay, it may be best to stay with the work/rest-sleep
pattern of the home base. In that case, combat unit members will not try tc'
adjust their circadian rhythms to local time. Possible techniques for
accelerating circadian adjustments will be discussed later in this manual.
Physiological and mental efficiency are influenced by the degree of
adjustment or lack of adjustment to the local day/night cycle. For example,
combat unit members working in the afternoon by local time may physiologically
be working at 0200 to 0600 hours by home base time. Thus, witho L adjustment to

12
local time, daytime performance would be poor, since 0200 to 0600 hours is the
circadian low point in performance efficiency. Leaders should be aware of this
inefficiency and plan the workload accordingly.
Combat Phase. By using a work/rest-sleep plan, the sleep manager can
avoid a situation where all personnel are physically and mentally exhausted at
the same time. However, operational demands may prevent adoption of optimal
work/rest-sleep and shift-work plans, and personnel will often experience
significant sleep loss. Counterdegradation measures can help under these
circumstances.
If the operation requirements make sufficient sleep impossible, personnel
should take advantage of any lull in combat to nap. Effective napping means
sleeping, not just resting.
Uninterrupted sleep for as little as 10 minutes may partially recover
alertness and help maintain job performance. However, the risk of sleep inertia
with naps of less than ten minutes (sor. Section 2.3) must be acknowledged,
especially during the combat phase. The sleep manager must balance the negative
effects of sleep (lost man-hours and sleep inertia), and the positive effect
(improved ability to perform a job after sleep).
Post-combat Phase. Immediately following an operation, combat unit members
should be allowed to sleep for up to 10 hours. Longer periods of sleep are not
desirable, as they tend to cause severe sleep inertia (see Section 2.3) and delay
getting back to normal schedules. Sleep lost during the operation need not be
replaced hour-for-hour. After one or two long recovery sleep periods, duration
should be within the normal range for subsequent sleep periods. The sleep
manager should be aware that sleep inertia lasting longer than five minutes, and
increased susceptibility to naps may occur during the week following SUSOPS.

13
 SECTION 4 PERFORMANCE DEGRADATION
Sleep management will: (a) prevent degradation in performance, mood, and
work motivation by devising the best work/rest-sleep plan for any operation; (b)
identify the symptoms of sleep deprivation and increase combat unit awareness of
those symptoms; and (c) overcome degradation by reallocation of jobs and use
performance aids.

4.0 Identifying Signs and Symptoms of Performance Dearadation

The signs and symptoms of sleep loss are variable. Different people have
different susceptibilities, and manifestations may be intermittent. However, as
sleep debt accumulates, signs and symptoms will be more prevalent and will
persist. When these may appear in a given person depends not only on the
accumulated hours of wakefulness, but also on individual tolerance to sleep loss,
types of tasks to be peLformed, severity of the physical workload, and time of
day (or point in the circadian cycle).
Mood and Motivational Changes. Early symptoms of insufficient sleep
include mood changes and decreased willingness to work. Combat unit members may
feel less energetic, less alert, less cheerful, more irritable, increasingly
negative, and sleepy. Individuals who regard sleepiness an-4 mood changes as
signs of weakness often deny negative moods and tiredness, but may admit to
decreased positive mood. After prolonged sleep loss, combat unit members will
pass from increased irritability and negativism to a sense of dullness and
weariness.
Impaired Attention. With progressive sleep loss, attention span becomes
shortened. Sleep-deprived individuals cannot concentrate on a job for long
periods of time. Intermittent, dreamlike, irrelevant thoughts or even brief
"micro-sleeps" cause lapses of attention.
Short-term Memory Loss. A common sign of sleep loss is the inability to
recall what one just saw, heard, or read. Memory loss is limited to recent
events or to short-term memory. A sleep-deprived individual often remains
confident about retaining messages, events, or data, only to find later that
these have been forgotten.
Variable and Slowed Responses. Under high work demands, the best response
time combat unit members can manage is affected only slightly by sleep loss. The
effect of sleep loss on response time appears not as a slowing down of all
responses, but as increased unevenness in response time. Some responses remain
fast, while others become very slow. The danger of sleep loss is the
unpredictable failure or slowing down of appropriate responses.
Vision Illusion/Hallucination. After more than 24 hours without sleep,
some combat unit members may experience visual hallucinations. The prevalence
of these hallucinations varies; some people never develop these symptoms.
Auditory illusions or hallucinations are rarely experienced.

14
 Failure to Complete Routines. Sleep loss causes carelessness toward such
routines as drying feet, changing socks, or filling up canteens whenever water
becomes available. Confirmation of verbal orders by repeating them aloud (the
standard operating procedure) becomes automatic, without effect, and eventually
disappears altogether.
Impaired Task Performance. Effectiveness in performing assigned tasks is
significantly lowered when CWEs exceed 24 hours. For example, after a 36-hour
CWE, a combat unit may be able to perform only 50% of the average message
coding/decoding work output expected in a normal workday. Similarly, members of
a combat unit may be able to detect only 70% of incoming signals. Task
performance is degraded due to impaired short-term memory; decreased ability to
concentrate; and intrusive, irrelevant, dream-like thoughts. Performance errors
most frequently result from failure to respond to task demands (errors of
omission); however, inaccurate responses to task demands (errors of commission)
also occur. Speed of reading written documents slows down. Comprehension is
good after sleep loss; however, combat unit members may experience difficulty in
remembering the directives in documents. Impaired performance follows a
circadian rhythm. The worst performances occur during early morning hours of the
time zone to which the person is adjusted.
Physical Exertion. Physical work performance is accompanied by a
subjective feeling of physical exertion ranging from very light to very
strenuous. The perception of exertion also follows a circadian pattern. In the
early morning hours, combat unit members may feel that more effort is required
to work at the same physical workload than if it were performed later in the day.
Sleep loss exaggerates this phenomenon so that combat unit members may want to
stop work because of the increased sensation of physical exertion. However, one
can continue working without causing physical harm.
Lack of Insight. In the ordinary, non-sleep-deprived state, insights into
our own behavior coincide fairly closely with the perceptions of others. If the
inadequate performance of a combat unit member is corrected, that person will
quickly remedy the problem because he recognizes it. However, with sleep loss,
the power of self-observation deteriorates so that combat unit members become
unaware of performance problems and may not even r(,cognize them when pointed out.
Failed Verbal Communication. Failed verbal communication is caused by
attention lapses combined with impaired short-term memory. Serious consequences
can occur when field commanders are afflicted.
Since sleep-deprived individuals fail to remain continuously attentive to
ongoing discussions, their conversation may become fragmented, wander, and
contain repetitive phrases and ideas. Impatience and/or weariness due to sleep
loss makes verb.il communication very difficult and tends to result in
misinterpretation. Members of the combat unit are less likely to have
misunderstandings if they are asked questions with the answers cross-checked.

15
Failed verbal communications can cause orders to be ignored. A sense of
numbness, omission of routines, arid impaired short-term memory can also
contribute to ignoring of orders.
Bickering is a manifestation of irritability caused by sleep loss.
However, bickering has one positive aspect: it shows that sleep-deprived
individuals are still talking to each other, exchanging orders and messages. The
frequency of bickering increases with increased sleep loss, up tc a point. It
decreases when sleep-deprived individuals begin to have difficulty continuing to
talk. As long as bickering continues, sleep-loss effects are not severe. A
subsequent decline in overall message exchanges and the amount of bickering is
a symptom of serious sleep loss. When bickering decreases, especially after a
period of increased bickering, individuals may be in a state of mental
ýxhaustion.
Signs of Jet Lag. As previously discussed, jet lag is commonly experienced
after rapidly crossing three or more time zones. The physiological, performance,
mood, and sleep effects of jet lag can compound the effects of sleep deprivation.
The presence or absence of jet lag must be considered when assessing the status
of combat unit members.
Signs of shift-work Fatigue. Some work/rest-sleep schedules cause
performance degradations similar to those caused by sleep loss and jet lag. A
"normal" work/rest-sleep schedule calls for an 8-hours-on/16-hours-off schedule
(i.e., 8 hours on duty, 16 hours off duty, with about 7 to 8 hours of continuous
sleep).
It is often necessary to use shift-work in a military operation, as the
available manpower pool is relatively fixed. Usually, the simplest way to plan
for shift-work is to divide available manpower into two or three teams, where
each team includes the supervision, skill-mix, and number of people necessary to
accomplish the task. These teams rotate, providing workers around the clock.
With three teams, a basic 8-hours-on/16-hours-off schedule can be established.
If only two teams can be formed, the workload per team will go up (i.e., a 12--
hours-on/12-hours-off schedule), and the length of rest periods will be shortened
correspondingly. occasionally, non-24-hour cycles (e.g., 8-hours-on/8-hours-off)
are necessary. However, such schedules can produce more stress and fatigue than
longer shifts with sleep available at the same time of day during each 24-hour
cycle. The work/rest-sleep plan must balance the demands of the task to be
accomplished against the fatigue (and resulting performance impairment.) expected
to accumulate. The physical signs of serious sleep loss are:
* Vacant stare - "glazed" eyes
* Blood-shot eyes
• Pale skin
• Body sways upon standing; sudden dropping of chin upon sitting
Intermittent loss of hand grip strength

16
 * Walking into obstacles and ditches
* Poor personal hygiene
* Very slow heart rate
* Loss of interest in surroundings
• Slurred speech

4.1 Preventing Performance Degradation

Sleep debt reduction best prevents fatigue-related performance degradation.
This requires a properly established work/rest-sleep schedule. If possible, at
least four to five hours of sleep (in a single, unbroken period) should occur per
24 hours in a single, unbroken period. This is enough sleep to prevent
performance impairment for over a month in the average person.
There are large, stable, individual differences in tolerance to sleep loss.
If one ranks a group of individuals in terms of tolerance to sleep loss (or
ability to work without sleep) from the highest to the lowest, this ranking will
remain stable across various sleep-restricting operations.
Tiring easily is not a personality weakness; the ability to do without
sleep is not a learned trick. Some individuals are born as long-sleepers and
others as short-sleepers. Short-sleepers tolerate sleep loss well; long-sleepers
do not.
It is important for combat unit members to know their sleep loss tolerance.
Some people may be overwhelmed by the loss of one night's sleep; some can take
sleep loss in stride. The work/rest-sleep schedule will set an optimal pattern
for 'he average person. If a person is sensitive to sleep loss, they should
sleep more frequently (nap), or for a longer period of time to lower the rate of
sleep-debt accumulation. If a person is tolerant to sleep loss, they can remain
awake a bit longer than the average person. However, everyone should be careful
of overconfidence in their ability to tolerate sleep loss. People succumb quite
suddenly to sleepiness when sleep loss continues beyond their tolerance,
certainly when it exceeds 72 hours. Being aware of this prevents the
catastrophic failure in job performance often seen among people who are
overconfident in their ability to ward off sleepiness.
Combat unit leaders are responsible to examine the operation scenario and
determine when and for how long combat unit members may be able to sleep.
Leaders must ensure that enough of the rest period entails actual sleep, since
only sleep can prevent sleep debt from increasing. Leaders must not only know
their own tolerance to sleep loss, but that of all others ii-, their command.
Combat unit members will suffer from imposed inaction and situational insomnia
when told to sleep when they a-e not sleepy. Their restlessness may disturb the
sleep of others in the unit.
Usually,. in extended combat, involuntarily falling asleep is a more serious
problem than situational insomnia or inability to sleep. However, field

LM............ 17

I
commanders should be prepared to deal with some individuals who cannot sleep
during the pre-miss on and mission phases. Individuals who are poor sleepers in
general will have worse sleeping problems under the increased stress and
disruption before and during a military operation. Effective use of sleep
training techniques can improve sleep under all circumstances. Sleep training
techniques are discussed in Section 6.

4.2 Overcoming Performance Degradation

When signs of performance degradation begin to appear among members of a
combat unit during SUSOPS, several preventive measures can be taken, such as
setting aside time for naps, changing routines, or rotating jobs, if persornnel
are cross-trained.
The most sleep-loss--affected member should be allowed to do a task that can
be accomplished at a pace set by the worker, not by the job. Sleep loss has less
impact on self-paced jobs. Everyone should be encouraged to write down work to
be done or messages received, and have others check what has been written for
clarity and legibility.
It is unlikely that two members of a combat unit will become incapacitated
by sleepiness at exactly the same time. Teaming up to do a job, or creating the
buddy system, is as valid a concept in SUSOPS as in SCUBA diving. The possible
use of pharmacological agents is discussed in Section 7.

18
 SECTION 5 SLEEP MANAGEMENT IN FIELD TRAINING
Sleep management is just one of many problems a field commander faces. As
the unit goes through predeployment, deployment, and combat phases, sleep
management may appear to have a low priority when compared with other tasks.
However, it is the responsibility of the field commander to see that combat unit
members comply with sleep management recommendations. If the field commander is
non--compliant with sleep discipline, sleepiness and sluggishness may result in
hazards to the combat unit. The best wdy to remain alert and responsive to
changing tactical environments is to plan for sleep. Taking naps during SUSOPS
is not a sign of low fighting spirit or weakness; rather, it indicates foresight.

5.0 The Work/Rest-Sleep Plan

The work/rest-sleep plan should ensure that sufficient hours of sleep are
available to everyone during all phases of a mission (see Section 2.1). Sleep
management is particularly important during the predeployment or pre-mission
phase, which tends to involve a heavy workload lasting over many days and weeks.
Reduction of sleep to four to five hours per 24 hours does not cause serious
degradation in cognitive task performances. Ideally, sleep mianagement should
seek to provide a minimum of four to five hours per day for all unit members.
If total sleep per 24-hour period must be reduced from a normal seven to eight
hours to less than four to five hours, careful sleep management is needed.
Anyone who sleeps less than four to five hours per day over an extended period
of time becomes more vulnerable to the effects of circadian rhythms and tiredness
after eating. Irritability and mood changes may occur, and communication with
others may deteriorate. Jobs involving hard physical work will amplify the
undesirable effects of sleep loss.
During a deployment phase, it is important to provide environments which
facilitate maximal sleep during rest periods. Sleep is facilitated by quiet,
dark environments. Social interaction should be restricted, but reading with a
small lamp is acceptable. Sleep loss is cumulative. If personnel are able to
sleep only two hours or less one day, quality sleep time should be made up by
sleeping five hours or more the next day; a key factor in sleep management is to
avoid accumulation of a large sleep deficit.
In pre-combat and combat phases of an operation, it is unrealistic to
expect that four to five hours of unbroken sleep per 24-hour period will be
available. If necessary, sleep can be ,aken in short periods of .0 to 30
minutes. This method, however, is less recuperative than long blocks of sleep,
so the longest feasible periods should be allotted. If sleep must be broken into
many short periods, a longer total amount of sleep will be needed to achieve the
same degree of benefit.
Sleep management is usually not considered necessary for the post-
combat/post-mission phase, but plays a significant part in regaining combat

19
 readiness. This is especially important when another comhat mission phase is
expected to follow shortly. The first post-combat/post-mission sleep period
should be allowed to extend either to spontaneous awakening or for 10 hours
(whichever comes first). This first recovery sleep should be arranged so that
there will be an awake period of 12 hours or longer before the next sleep period.
Inadequate sleep management will delay re-adjustment to a routin3 work/rest-sleep
schedule.

5.1 Signs of Degradation

Review Section 4.0

5.2 Tolerance to Sleep Loss

Review Section 4.1

5.3 The Ability to sleep

There are many factors in the field which tend to prohibit sleep.
Sometimes combat unit members may not want to sleep so as not to miss exciting
events. However, distractions must not cause sleep to be shortened to less than
four hours per 24-hour period. Combat unit members must be disciplined to take
naps. Napping is not a time-wasting luxury, but is mandatory for maintaining
performance under conditions where opportunity for sleep is limited.

5.4 Aids to Measure Sleep Loss

Three aids that can help a field commander apply sleep management during
a field exercise are: a) a sleep log; b) a mood scale; and c) the "Plus 7 Task."
Sleep Lo . The best way to manage sleep in the field is to keep a sleep
log. From the predeployment phase to the post-deployment phase, records of all
sleep and nap periods should be kept. A record of total hours of sleep
accumulated over the operation period should be included. Such a record will
help to ensure that combat unit members are sleeping at leant four to five hours
par 24-hour period. If a sleep log shows that total hours of sleep (including
nap periods) are less than four hours per 24-hour period, the first available
long rest period must be used for sleep.
If combat unit members have not slept for 48 or inure hours, a sleep period
should be two hours or longer, if at all possible. While any sleep is
physiologically better than none, sleep inertia may be worse after shorter naps
in such sleep-deprived individuals. Also, the psychological difficulty of having
to awaken so soon can impact motivation negatively. This is especially important
if the sleep period should fall from 0200 to 0600, the circadian rhythm trough.
The combined effects of a deeper circadian low (caused by sleep loss) and the
sleep time being too short may cause personnel to feel they cannot go on.

LM"
20
 A sleep log can be very simple. Sleep managers can write down the length
of time combat unit members have slept, or the time sleep begins and the time of
awakening. It should also be indicated whether or not combat unit members did
moderate or heavy physical work.
An example of a convenient sleep log is included in Appendix 1. The upper
and lower parts of the page represent the front and back of a 5" x 8" index card.
By adding up the number of 30-minute boxes marked with a line to indicate sleep,
it is possible to calculate the approximate amount of sleep that occurred in the
given 24-hour period. If a sleep log card is filled out each day during an
operation, the degree of accumulated sleep debt can be estimated at any time
(Total Sleep/Number of Days = Sleep per Day; this should be at least 4 hours per
day). You should probably consider a given sleep debt more severe if the
majority of sleep has been taken in many small segments rather than a single
sleep period per 24 hours.
The questions on the front of the card are phrased to fit a single sleep
per 24-hour pattern, which may well not be the case under operational conlitions.
However, they indicate general types of information that may be valuable to sleep
managers in making sleep logistics decisions.
Knowing how long it takes a person to fall asleep and whether that sleep
is uninterrupted gives you a picture of how efficiently a given sleep period is
being used. If someone has a two-hour period for sleep, but one hour is used
waiting to fall asleep with repeated awakenings, then half the possible sleep
time is wasted. In such a situation, the sleep environment should be improved
if possible. Also, the individual might conbider specifically training his sleep
habits when he is out of the operational situation, to prevent such problems
during future operations.
How rested a person feels, and whether there is a perceived need for more
sleep, relate both to how restful sleep is, and the severity of the accumulated
sleep debt. The mood scale serves as an abbreviated estimate of the more complex
mood scale, should that not be available. Hours of work in the last 24 hours
provides an indication of how much sleep limitation is based on workload, and how
much leeway there might be for additional sleep. The "Remarks" section can be
used for recording the presence and quantity of physical exertion.
The sleepiness scale on the back of the card (lower portion of the page)
measures sleepiness subjectively. The way we feel during the late morning and
afternoon of a day following a good night's sleep with no sleep deprivation in
the recent past, is represented by response (1). The way we feel in the middle
of the night after many days without sleep is represented by response (7).
Subjective sleepiness can be very helpful in assessing the impact of sleep
deprivation. However, military personnel (perhaps particularly elite groups such
as SEALs) nviy be reluctant to admit feeling sleepy, considering it evidence of
weakness. Thi- caxi make the subjective sleepiness measure worthless. Sleep

21
managers need to convince those under their commands of the importance of
answering this sleepiness scale objectively and honestly. With accurate answers,
this scale can help assess whether a sleep plan is adequately fulfilling the
sleep needs of personnel.
Mood Scale. A field commander should watch the moods of combat unit
members for early signs of accumulating sleep debt. Since leaders know these
people, they will probably be aware when their moods change from positive and
energetic to negative, jittery, and defiant.
A more objective means of determining how rapidly combat unit members'
moods are changing is a mood scale, such as the NAVHLTHRSCHCEN Mood Scale
(Append.x 2). The NAVHLTHRSCHCEN Mood Scale consists of 19 positive and 10
negative adjectives describing moods.
Once personnel become familiar with the mood scale questionnaire, it will
take less than a minute to score positive and negative changes in mood. The
questionnaire should be administered to combat unit members before an operation
begins, as well as while it is in progress. This enables the field commander to
detect subsequent increases in negative mood, and decreases in positive moods,
by comparing with the baseline phase.
Plus 7 Task. The effects of inadequate sleep can sometimes be masked when
personnel put forth extra effort toward their assigned tasks. This is laudable
evidence of professionalism. However, this masking may be misleading and may
prevent appropriate preventive measures. It may appear that sleep loss is not
affecting personnel; yet a short time later, combat unit members may show serious
performance degradation.
Moderate physical work and excitement may also mask performance
degradation. However, during the post-physical-work period, combat unit members
will show greater deterioration of cognitive performance. The combined effects
of physical work and sleep loss cause increased fatigue and sleepiness once the
physical activation ind excitement wear off.
The best, way to detect early degradation in mental task performance,
despite such masking, is to have combat unit members do an over-learned task of
a rather boring nature, such as the "Plus 7 Task". The Plus 7 Task tests short-
term memory, which is affected by sleep loss. It reliably detects mental
degradation.
The Plus 7 Task consists of continuous additions. A random number between
b and 9 (for example, 9) is picked. A short mental calculation is performed by
adding 7 to the number (9 f 7 -- 16). The calculation is performed again using
the previous sum (16 A7 = 23). These additions are all done in the head,
remembering the sum and calculating the new sum by adding 7. When combat unit
members can continue to do the Plus 7 Task correctly for one minute or longer
without long pauses, they do not have severe sleep loss effects. If a particular
individual is to be tested, the individual should say thie sum aloud as it i.s

22
calculated. The sleep manager should note how steady and accurate this
individual is in performing the task. Check the accuracy of the answers with a
table listing a sequence of the correct sums (Appendix 3). However, more
important than accuracy is whether a person can do repeated additions without
long pauses. A few minutes of the Plus 7 Task, preferably with eyes closed, will
reveal any mental degradation due to sleep loss.
As with the mood scale, the Plus 7 Task must be administered prior to the
start of the operation to assess baseline performance. Testing should
subsequently be given at least once each 24-hour period, preferably several times
a day. A substantial decrease in the total number of additions completed, as
well as increased number of long pauses or inaccurate additions, indicates
deterioration.

5.5 Sleep Facts

A combat unit field commander/sleep manager needs to understand sleep.
Following are some basic facts about sleep:
* Resting on a bed is not the same as sleep. During the deployment
phase, many soldiers may be resting, but not sleeping, due to
excitement. Make certain that people are asleep, not merely
resting.
* People typically become sleepy at least twice a day: once in the
afternoon and once during the habitual sleep time.
* There is evidence that a small amount of extra sleep can be stored
in our bodies. Sleeping a little longer than the normal seven to
eight hours (achieved by going to bed early rather than sleeping
late) before deployment may increase tolerance to subsequent sleep
loss. However, the important thing is not to begin a prolonged
operation already sleep-deprived. Most people live in a chronic
state of mild sleep deprivation; therefore, the main benefit of
sleeping a little longer during predeployment may be to counter
existing sleep deprivation.
* Excessively prolonged sleep periods (more than 10 hours) should be
avoided, as they may cause exaggerated sleep inertia and a
paradoxically increased feeling of sleepiness.
* To aid uninterrupted sleep, the bladder should be emptied before
attempting to sleep. Waking up to urinate interrupts sleep, and
getting in and out of: bed can di~sturb others trying to sleep.
* During daytine or early morning naps, many people experience vivid
dreams an they afall asleep, often waking up frightened. To some
soldiers, the dreamns may have a component of situational anxiety.
Members of the combat unit should be reassured that vivid dreams are
quite cnimuon in daytime slI eep.

23
There are several stages of sleep: stages 1, 2, 3, 4, and rapid eye
movement (REM). Many Studies have shown that the total amount of
sleep, not the amount in a specific stage, is most important. The
body will take care of the type of sleep obtained, if sleep time is
available.

24
 SECTION 6 SLEEP TRAINING

6.0 Sleep Training

Many behaviors affect sleep. Most people will experience some degree of
sleep impairment when required to sleep under less-than-optimal conditions (e.g.,
wrong time of day, noisy or uncomfortable environment, presence of emotional
stress). Anybody who starts out with poor sleep under ideal conditions is likely
to sleep especially badly under difficult conditions.
In a young, healthy population such as Navy SEALs, a normal sleeper can
fall asleep within 20 minutes, sleep seven to eight hours without any sleep
disruption, and awaken in the morning feeling refreshed and alert. If a person
has difficulty falling or staying asleep, or awakens in the morning feeling
poorly rested, he or she is a poor sleeper and may suffer greater performance
impairment during intense sleep-restricting operations. All military team
members should train themselves for optimum sleep. A questionnaire to determine
combat unit members, habits is included in Appendix 4.
Using sleep training techniques can improve sleep in general, and help
ensure that individuals are well-rested with no sleep debt prior to deployment.
In addition, the sleeping skills developed through sleep training will enable
personnel to use the limited time that may be available for sleep during military
operations most efficiently. If the sleep questionnaire indicates any sleep
problems, the following tips will be helpful.

6.1 Summary of Good Sleep Techniques

* Optimize your circadian rhythms by: getting up, eating meals,
exercising, and going to bed at the same time every day.
0 Use the bed only for sleeping.
0 Do the same thing every night before bed. This should be a short
sequence of behaviors, starting before going to bed, and ending with
a relaxing image to clear alerting thoughts from the mind.
0 Establish a time and place for worrying other than at bedtime, and
use it every day.
0 Except during prolonged operations or before night Missions, do not
nap. It is best to sleep for a set duration (ideally, seven or
eight hours) at the same time each night.
0 Do not lie down during the day. Do not lie awake in bed for long
periods. Get up and do something boring to bring on drowsiness.
0 Avoid stimulants (coffee, caffeinated soft drinks, tea) after early
afternoon. Avoid excessive alcohol. Avoid sleep-induclng
medications. Avoid tobacco produc"-s.
6 Learn a muscle relaxation technique.

* Have a positive attitude about sleep. Sleep is not just some

mysterious event that happens to us; it is a behavior that can be
control led.

25
 SECTION 7 DRUGS
7.0 Stimulants: Non-operational Use
CaffeLne is a very potent stimulant drug. People who drink caffeinated
beverages late in the day, after dinner, or close to bedtime generally have
impaired sleep. They may have difficulty going to sleep or awaken easily during
the night. They are often able to go to sleep, but the sleep is lightened by the
stimulant. in this case, the person may not be aware of a sleep problem, but may
not feel rested in the morning or may tend to get tired early in the evening.
If more caffeine is used to counter this fatigue, there will be further impaired
sleep. It is important to remember that coffee is not the only source of
caffeine. Most soft drinks and tea contain caffeine, and even chocolate contains
a stimulating caffeine-like drug called theobromine. Many medications also
contain caffeine. A number of over-the-counter pain killers contain caffeine.
All of these products should be avoided after early afternoon when working a
standard daytime-work/nighttime-sleep schedule.

7.1 Stimulants: Operational L'-e

When working under an unusual or SUSOPS--type schedule, it is not unusual
to use stimulant medications to try to counter the effects of sleep deprivation
or circadian rhythms on alertness and performance. Such use should be controlled
and carefully monitored. Most stimulants affect performance in a pattern known
as an inverted "U"-shaped curve. This means that they appear to improve
performance with increasing doses up to a point. But as the dose is increased
further, p:lerformance starts to deteriorate and may even drop below baseline.
Thus, drin'king 20 cups of coffee a day to try to counter sleep deprivation
effects may ',irther hinder performance because of jitters and nervousness.
Another fa -, o consider is that many drugs hi ve less effect if consumed
regularly. '..-utinely consuming large amounts of caffeine-containing products may
decrease the effects of caffeine when really needed.
There are stronger stimulants than caffeine available by prescription. In
very special limited circumstances, such medications might be used during a
military operation. The most likely agents to be prescribed would be
amphetamines, pemoline, or methylphenidate. It is not yet known which is the
best agent. Pemoline has the advantage of being nonaddictive. In any case,
medications should only be used under a doctor's direction.
If a stimulant (especially a strong one) must be used, a countering
medication may be required later. For example, air crews who used stimulants to
ward off fatigue when returning from distant missions, have reported great
difficulty sleeping afterwards. Interference with recovery sleep could impair
performance on subsequent missions. Thus, use of a stimulant may require
subsequent use of a sedative -again, only under a doctor's direction,

26
7.2 Sedatives
Under most circumstances, sleeping pills are not recommended for military
personnel. In an operational situation, the risk of impairing critical
performance is high. People are basically useless for the first four to six
hours after taking a sleeping pill. Some sleeping pills impair activity the
following day or even longer. Also, many sleeping pills suppress dreaming,
causing less restorative sleep.
Even under non-operational circumstances, sleeping pills are not
recommended. Using sleeping pills over an extended period can cause dependency.
Additionally, sleeping pills can decrease effectiveness of the sleep training
techniques discussed in Section 6.
One possible circumstance where sleeping pills might be appropriate for
military use is with rapid transport, across multiple time zones. When personnel
are deployed to a distant location and need not engage in critical work soon
after arrival, use of a sleeping pill to facilitate sleep during transfer, or
promote sleep synchronized with the new time zone after transfer, might decrease
the fatigue-related effects of jet lag. If effectiveness is demonstrated in
scientific tests, new products may later become available to facilitate sleep
without the side effects of sleeping pills.
Another possible situation where sedatives might be used is to allow sleep
after stimulant ingestion, as was discussed in the preceding section.

7.3 Other Medications

Although nicotine is not an effective stimulant in general, those who are
addicted to it may perform less well when deprived of it. Also, when a smoker
(or a smokeless tobacco user) is asleep, his body starts to go into nicotine
withdrawal. This often causes smokers to wake up during the night. Nicotine has
a very broad range of effects on the body, including the cardiovascular system.
It is
possible that some of these effects could interact in a negative or even
dangerous manner with the effects of some military activities (e.g., diving).
Additionally, tobacco products, including smokeless tobacco, have well-
established negative effects on health.
Alcohol can also cause sleep problems. First, as with any depressant drug,
there is a n ,ed for more and more alcohol to induce sleep. Second, alcohol is
metabolized very rapidly. A few hours after consuming alcohol, the body begins
to withdraw from the effects, causing light,- sleep and a tendency to wake up.
Third, alcohol suppresses dreamin9. Dreaming is a very important aspect of
sleep. Heavy alcohol users show chronic abnormalities in sleep. The deepest
type of sleep is lost, as is observed in the very old, and a given period of
sleep will be less restorative. Once these changes have occurred, they may
persist, even after -1cohol is no longer being used.

27
 Most cold and allergy medications can affect either alertr.ess or sleep.
Many antihistamines tend to cause sleepiness. There are antihiztamines that do
not affect the brain (for example terfenadine or Seldane), but they are not
currently available over the counter. If an antihistamine is needed, a physician
should prescribe a non-sedating product. Most decongestants can prodiuce a
stimulant effect. If taken near bedtime, decongestants may impair sleep. When
uncertain whether a particular product contains an antihistamine or a
decongestant, consult a pharmacist.

28
 SECTION 8 THE EFFECTS OF LIGHT
Light has two effects on alertness and sleep. First, there is a direct
alertino or energizing effect. When personnel are sleep-deprived, wcrking in a
brightly lit area, preferably in sunlight, will help maintain maximum
performance.
The second effect of light is indirect, via adjustment of circadian
rhythms. Normally, everyone has a slight adjustment to his or her circadian
rhythm each day. Curiously, the natural cycle of the internal circadjan clock
is not actually 24 hours; it is closer to 25 hours. Therefore, without
adjustment, people would gradually
slide in and out of phase with the world,
experiencing periods of jet lag without going anywhere. However, various stimuli
advance the clock each day to keep the body cycling at 24 hours. One of the most
important stimuli is bright-light exposure in the morning, which can be employed
when the circadian rhythm needs more extensive adjustment, as in jet lag. For
example, if
you have flown eastward across six time zones, you now need to be
waking earlier and going to sleep earlier relative to your previous time zone.
Bright-light exposure during the time period corresponding to morning in your
original time zone will tend to push your rhythm forward. With a six-hour shift,
this would correspond to the early afternoon period (i.e., 0700 to 1000 in your
original time zone would correspond to 1300 to 1600 in your new time zone). This
is the time when one should get bright-light exposure to assist in adjusting to
the new time zone. Bright-light exposure during the time period corresponding
to evening in your original time zone, has the reverse effect. Bright-light at
the wrong time tends to cause you to go to sleep and awaken later. Therefore,
after an eastward flight, you would want to avoid evening light. After a
westward flight, you should avoid morning light and seek evening light (again,
remember, "morning" and "evening" are defined by your original time zone).
Special artificial lights are becoming available to facilitate correctly timed
bright-light exposure under conditions when natural sunlight is unavailable.
Light visors and light masks to provide controlled, individual light exposure are
currently being tested and may be helpful during transport, but we need more
definitive studies.
Controlled light exposure can also be used to shift a person's circadian
rhythm deliberately out of phase with local time. For example, someone who needs
to work the night shift might want to be as much as 12 hours out of phase with
local time. This is possible with timed bright-light exposure. However, it
requires careful protection from bright-light exposure at the wrong time of day
and conformance to the new sleep-wake cycle (i.e., you can't work the night shift
during the week,play by day on the weekend, and expect your body to be in phase
with your work schedule). Under controlled military conditions, this may be
possible. Exposure to artificial bright light could be used first to shift the
circadian rhythm to the new work/rest schedule and then continued (with daily
treatment during the morning) to maintain synchronization with that schedule.

29
 SECTION 9 CONCLUSIONS/SUMMARY

Sleep research at the Naval Health Research Center (and many other research
centers), has concluded that:
1. A total sleep duration of four to five hours per 24-hour period is
the minimum amount required to maintain an acceptable level of
performance (but with poor mood, fatigue, lowered motivation, and
general malaise).
2. All sleep stages contribute equally to recovery from sleep loss.
That is, one sleep stage is as effective as another in removing the
undesirable effects of sleep loss.
3. It is preferable to sleep for a single, uninterrupted period rather
than to take many short sleep episodes. However, short naps (20 to
40 minutes) are better than no sleep at all.
4. The body and its functions are influenced by circadian rhythms.
Sustained operations cause varying degrees of sleep debt, leading to
decreased combat effectiveness and hidden cost in manpower resources. The
process of removing sleep debt is quite similar to that for removing hunger.
Hunger is eliminated by eating food; food logistics work scientifically to reduce
hunger. Similarly, sleep logistics (management) will work to reduce sleep debt.
Sleep management guidelines can help evaluate and prevent the degrading effects
of sleep loss on performance, moods, and motivation to work.
The most important steps to be taken in a non-pharmacologic approach to
sleep management are summarized below:
* First, and most important, prepare a work/rest-sleep plan to meet
sleep needs. Sleep needs are satisfied only by sleeping.
* Second, utilize appropriate self-diagnostic techniques and
performance aids to detect and compensate for sleep loss (sleep
debt).
• Third, make sure personnel have good sleep skills that facilitate
optimum use of opportunities for sleep before, during, and after an
operation.

Important points to remember about effects of pharmacological agents in

sleep management are summarized below:
* Any drug that helps keep you awake may prevent you from sleeping
when you need to, and any drug that helps you to sleep may have
hangover effects on performance.
* If a drug like caffeine is used repeatedly, it may have less effect
than if used only once.
0 Nicotine withdrawal can impair the sleep of tobacco users.

30
 FURTHER READINGS

NOTE: For ease of readability for users of this manual, references used in
preparing this manual are cited only in the bibliography, and not in the
text. Please contact the authors at the address given for further
information about specific reference citations.

Beckett, M.B., Goforth, H.W., & Hodgdon, J.A. Physical fitness of U.S. Navy
special forces team members and trainees. 1989. Technical Report No. 89-29.
Available from: Naval Health Research Center, San Diego, California.
Borbely, A. Secrets of Sleep. Basic Books, New York, 1986.

Bourke, D.H. The Sleep Management Plan. Harper, San Francisco, 1990.
Coleman, R.M. Wide Awake at 3:00 A.M.: By Choice or by Chance. W.H. Freeman,
New York, 1986.

Dinges, D., and Broughton, R,, Eds. Sleep and Alertness: Chronobiological,
Behavioral, and Medical Aspects of Napping. Raven Press, 1989.
Dotto, L. Losing Sleep: How Your Sleeping Habits Affect Your Life. William
Morrow, New York, 1990.
Horne, J. Why We Sleep: The Functions of Sleep in Humans and Other Mammals.
Oxford University Press, Oxford, 1988.
Meddis, R. The Sleep Instincts. Routledge & Kagan Paul, London and Boston,
1977.

Office of Technology Assessment. Biological Rhythms: Implications for the

Worker. Office of Technology Assessment, Congress of the United States. OTA-BA-
463, Washington, D.C.: U.S. Government Printing Office, September 1991.

Scott, A.J., Ed. State of the Art Reviews Occupational Medicine: Shiftwork.
Hanley and Belfus, Philadelphia, 1990.

31

i , I I II I I i, , •.
APPENDIX I
SLEEP LOG

A-1
 I, s.nnnonpn'cn l duo 1....T n o-!ni i-'iI]in
i, 'yhiltiiip• l I -,nrinrC
[).,y I M•lI

LI........ 77TIIIIY iLJ I..1!2hJ I'... .. 1....

.. i
n-,Ti.did yoh h 9.-9 In siey Iasi nigti Tr It (loll uslet' 3 . nt y times do y.,, i.~a I

NONE ]l IGriT ,' " F R A'TI

A r DII Al t•LF
ii-'iI iNltTt ,.hl" u

Ho rePoted do tii, feel' S Co nv leel that you coujid hate

uiied m~ore sleep•
""IWELL
Rr)IUD .. DIRAT[ILt Rý51(U SL.
. t .. N.): I A IALt•1I '_ IY-I S
Y(¶ '

, ode,'s Mood 1 d,--, ,Ie-le 1••

Ho,., -iIa•

VLRY PL07P POOR AY( RAG[ .j ,OLX ...........

-.

SE'.ErP LOG 1iNO.COM-6520/i (REV. 4.74) NANPRU (11-70l

Choose one of the sever stotements below whch best describes your present feelings. How you feel right now.

(1) Feeling active and vilOl, alert, wide awake.

(2) Functioning of a high leel, but not at peolk, able to concfntrate,

(3) Relaxed; owoke, responsive, but not ot lull alertness.

(4) A little foggy, let down, nor at peak.

(5) Foggy, slowed iu'wn. beginnirg to lose iterest in remaoning awake.

(6) Sleepy, waooty prefer to be lying down, lighting sleep.

(7) Almost in reverie; sleep onset soon, losing struggle to rieman awake.

T-2ANIUP' LPINI SCAI I

A- 2
 APPENDIX 2
NAVHLVHRSCHCEN MOOD SCALE

A-3
 NAVAL HEALTH RESEARCH CENTER
MOOD QUESTIONNAIRE
This 29 item questionnaire (NHRC MQ) uses a four point Likert
type response scale (not at
all = 0; a little 1; quite a bit = 2; extremely = 3). There are two scales reflecting
the bi-factor theory of moods. These scales were derived using the principle
solution on limited data samples. components
The items in these scales and the scale ranges are:

Nýýgative Scale: annoyed, defiant, drowsy, dull, grouchy, jittery, sleopy, sluggish,
tense, tired

(simple sum of 10 item scale responses; range 0 - 30)

Positive Scale: active, alert, carefree, cheerful, able to communicate,
dependable, efficient, friendly, full of pep, good-natured, happy, considerate,
kind, lively,
pleasant, relaxed, satisfied, able to think clearly, able to work
hard
(simple sum of 19 item scale responses; range 0 - 57)
Moses, J.M., Lubin, A., Naitoh, P. & Johnson, L.C. (1974). Subjective evaluation of the
effects of sleep loss: The NHRC Mood Scales. Technical Report 74-24, Naval Health Research
Center, San Diego, CA.

NPRU MOOD SCALE

1IND-COM-6520/2 (5-73) Instructions: For each item, choose one of the four answers
that best describes how you feel now. Then put an "X" in that
box.
NAME AGE SEX DATE
ITEM NOT AT ALL A LITTLE QUITE A BIT EXTREMELY
ACTIVE
ALERT
ANNOYED
CAREFREE
CHEERFUL
ABLE TO CONCENTRATE
CONSIDERATE
DEFIANT
DEPENDABLE
DROWSY
DULL
EFFICIENT
FRIENDLY
FULL OF PEP
GOOD-NATURED
GROUCHY
HAPPY
JITTERY
KIND
LIVELY

A-4
 APPENDIX 3
PLUS 7 TASK TABLE

A-5
 PLUS 7 TASK TABLE

1 2 3 4 5 6 7 8 9
8 9 10 11 12 13 14 15 16
15 16 .17 18 19 20 21 22 23
22 23 24 25 26 2 7 28 29 30
29 30 3] 32 33 34 35 36 37
36 37 38 39 40 41 42 43 44
43 44 45 46 47 48 49 50 51
50 51 52 53 54 55 56 57 58
57 58 59 60 61 62 6:3 64 65
64 65 66 67 68 69 70 71 72
71 72 73 74 75 76 77 78 79
78 79 80 81 82 83 84 85 86
85 86 87 88 89 90 91 92 93
92 93 94 95 96 97 98 99 100
99 100 101 102 103 104 105 106 107
106 107 108 109 110 111 112 113 114
113 114 115 116 117 118 119 120 121
120 121 122 123 124 125 126 127 128
127 128 129 130 131 132 133 134 135
134 135 136 137 138 139 140 141 142
141 142 143 144 145 146 147 148 149
148 149 150 151 152 153 154 155 156
155 156 157 1.58 159 160 161 162 163
162 163 164 165 166 167 168 169 170
169 170 171 172 173 174 175 176 177
176 17"7 178 179 180 181 182 183 184
183 184 185 186 187 188 189 190 191
190 191 192 193 194 195 196 197 198
19/ 198 199 200 201 202 203 204 205
204 205 206 207 208 209 210 211 212
211 212 213 214 215 216 217 218 219
218 219 220 221 222 223 224 225 226
225 226 227 228 229 230 231 232 233
232 233 234 235 236 237 238 239 240
239 240 241 242 243 244 245 246 247
246 247 248 249 250 251 252 253 254
253 254 255 256 25"7 258 259 260 261
260 261 262 263 264 265 266 267 268
267 268 269 270 271 272 273 274 275
274 275 276 277 278 279 280 281 282
281 282 2833 284 285 286 287 2838 289
288 289 290 291 292 293 294 295 296
295 296 297 298 299 300 301 302 303
302 303 304 305 306 307 308 309 310
309 310 311 :312 313 3.14 315 316 317
316 317 318 319 320 321 322 323 324
323 324 325 326 327 328 329 330 331
330 331 332 333 334 335 336 337 338
337 338 ]39 340 341 342 343 344 345
344 345 346 347 348 349 350 351 352
351 352 :353 354 356 357 358 359 360
:358 359 360 361 362 363 :364 365 366
365 366 36"7 368 369 370 371± 372 3'/3
372 373 374 375 376 3'17 378 379 380
379 380 381 382 383 384 385 386 387
386 387 388 389 390 391 392 393 394
393 394 395 396 397" 398 399 400 40]
400 401. 402 403 404 405 406 407 408
407 408 409 410 411 412 413 414 415
414 415 416 417 418 419 420 421 422

A-6
 APPENDIX 4
SLEEP QUESTIONNAIRE

A.-7
NHRC SLEEP QUESTIONNAIRE
(8/15/78)
Page 1 Today's Date

NAME RANK/RATE RATING

SEX SOC SEC # DATE OF BIRTH AGE

CURRENT DUTY STATION DATE ASSIGNED

Instructions: Please fill in the blanks or circle the answer that best
applies to you. The completion of this questionnaire is voluntary. This
information will. be used for research only, and will not become a part of
your permanent service record. THE QUESTIONS BELOW ARE ABOUT YOUR USUAL
SLEEP NOW.

For question~s 1 and 2, please use 24-hour clock times:

1) At what clock time do you usually 7) If you have trouble falling asleep,
go to bed on workdays? what is it that keeps you awake?
On days off? 1. Thoughts running through my mind
2. Aches and pains
2) At what clock time do you usually 3. Too much noise
wake up on workdays? 4. List any other
On days off?
5. Does not apply to me
3) On workdays, do you go to bed and
get up at fixed, regular times? 8) If you have trouble falling asleep,
1. Always or almost always do you:
2. Often 1. Just lie in bed
3. Sometimes 2. Turn on the light and read
4. Never or almost never 3. Get up
" List any other
4) How long does it usually take you
to fall asleep after lights-out? 5. Does not apply to me
;Hours . .. Minutes
9) Do you take anything to help you
5) Do you ever have trouble falling fall asleep?
asleep? 1. Never or almost never
I. Never or almost never 2. Sometimes
2. Sometimes 3. Often
3. Often 4. Always or almost always
4. Always or almost always
10) If you take something to help you
6) If you OIo have trouble falling you fall asleep, what is it?
asleep, how often docs this happen? I. Medicine prescribed by a doctor
1. Less than once a year 2. Non-prescribed medicine
2. Less than once a month 3. List any other
3. About once a month 4. Does not apply to me
4. 1 or 2 times per week
5- 3 or 4 times per week
6. 5 ( , more times per week
7. Does not apply to me
A-8
11) How many times during your 17) How long do you usually sleep
usual sleep period do you wake during your naps?
up by yourself and then go back 1. Between 10 and 30 minutes
to sleep? 2. Between 30 and 60 minutes
1. Rarely or never 3. Between 1 and 2 hours
2. 1 or 2 times 4. More than 2 hours
3. 3 or 4 times 5. Does not apply to me
4. 5 or 6 times
5. 7 or 8 times 18) Do you have disturbing dreams or
6. 9 times or more nightmares?
1. Never or almost never
12) On how many days per week does 2. Sometimes
this happen? 3. Often
1. 1 or 2 days per week 4. Always or almost always
2. 3 or 4 days per week
3. 5 or more days per week 19) Overall, what kind of sleeper are
4. Does not apply to me you?
1. Very good
13) When you wake up during your 2. Good
usual sleep period, how long 3. Average
does it usually take to go 4. Poor
back .o sleep? 5. Very Poor
1. 10 minutes or less
2. 10 to 20 minutes 20) If you are a poor or very poor
3. 20 to 30 minutes sleeper, is this because you
4. 30 minutes to an hour (mark most important)
5. More than an hour 1. Have trouble falling asleep
6. Does not apply to me 2. Wake up and have trouble going
back to sleep
14) Do you wake up too early and find 3. Have disturbing dreams or
you cannot go back to sleep? nightmares
1. Never or almost never 4. Are awakened frequently by noise
2. Sometimes 5. Wake up too early (early morning
3. Often awakening)
4. Always or almost always 6. Wake up tired
7. Other
15) On how many days per week does 8. Does not apply to me
this happen?
1. 1 or 2 days per week 21) If you are a poor or very poor
2. 3 or 4 days per week sleeper, how long have you had a
3. 5 or more days per week sleep problem?
4. Does not apply to me 1. 1 to 6 months
2. 6 months to 1 year
16) How often do you take naps.? 3. 1 to 2 years
1. Parely or never 4. 3 to 5 years
2. Less than once a month 5. 5 to 10 years
3. About once a month 6. As long as I can remember
4. 1 or 2 times per week 7. Does not apply to me
5. 3 or 4 times per week
6. 5 or more times per week 22) Were (or are) any members of your
7. More than once a day family poor sleepers, that is,
have sleep problems?
Yes 1 No 2
A-9
23) If yes to #22, which family 29) How much do you smoke each day?
member, or members, if more 1. None
than one? 2. Less than 1 pack
1. Father 3. 1 pack
2. Mother 4. 2 packs
3. Brother 5. More than 2 packs per day
4. Sister
5. Does not apply to me 30) How much coffee, tea, or coke do
you drink per day? (if coke, circle
24) Do you usually feel well-rested coke)
after you wake up and first get 1. None
out of bed? 2. 1 cup or 1 coke
1. Always or almost always 3. 2 to 3 cups or 2 to 3 cokes
2. Often 4. 3 to 5 cups or 3 to 5 cokes
3. Sometimes 5. More than 5 cups or 5 cokes
4. Never or almost never

25) Which choice below best describes

how you usually feel for the first
2 or 3 hours after you wake up from
your normal sleep period on workdays?
1. Alert, wide awake
2. High level, but not at peak
3. Awake, but relaxed
4. A little foggy, let down
5. Slowed down, sleepy
6. Fighting sleep
7. Almost asleep
26) Which choice below best describes how
you usually feel in the afternoon,
between 1500 and 1700?
1. Alert, wide awake
2. High level, but not at peak
3. Awake, but relaxed
4. A little foggy, let down
5. Slowed down, sleepy
6. Fighting sleep
7. Almost asleep
27) Do you ever fall asleep even though
you are trying hard to stay awake?
1. Never or almost never
2. Sometimes
3. Often
4. Always or almost always

28) Are you easily awakened by noises?

1. Never or almost never
2. Sometimes
3. Often
4. Always or almost always

A-1O
 APPENDIX 5
MISSION EXAMPLE

Figures A--I and A-2 show the sleep/wake patterns of participants in a SEAL
training exercise. Sleep periods for each individual across the eight days of
the exercise are marked by lines. The normal sleep periods (2200 to 0600) are
marked by the shaded areas. The graph shows reduced amounts of sleep, with short
fragmented sleep periods often occurring outside of the ideal sleep time.
Participants in the exercise accumulated serious sleep debts. The men in this
exercise felt this was a very difficult schedule and reported that they
experienced extreme fatigue. This is an example of a mission where application
of sleep management might have improved the alertness, mood, and general
performance of the participants.

A-II
 ZT-V

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U GO SIAVN i.ir
 ET-V

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S.0 .0 %-# %0 %.0 %.a%0 %.0 %w %-v %-0S % S

aeC. aZ 0 >a fl

C# c1) SiVIIINI ±03rans

 Fonn Approved
REPORT DOCUMENTATION PAGE OMBNo.071W0IN

Pubhc rporr,,g burden for ha *Wkt~ion of informatlon is eanhnated toavseie I hour per response, for avwmtng Inamietiona. se•rchung
nlding the ornie
exianlg dam source, gaitheuing ard mantanirng tOe d*M neded, And crxnj'ering ed mvwa.g &hecoln of linowrwTmon. Send ommwwenm regarding ti
burden eslnmai or any odtwheae of fa miection of Informlon, inruding suggeboCna for rdung this burden, io Waahington Headquanaira Semoma,
Directorai for InformagOn Operalonz " Repons, 1215 Jefferorln Dvis Highway. S&ite 1204, Mrltngton, VA 22202-4302, and to fe Office of Lbuagernent
and Budget, PaperworklFeducon Properc (0704.-0188), Wainglon. DC 20503.,
1. AGENCY USE ONLY (Leave blank) 2. REPORT DATE 3. REPORT TYPE AND DATE COVERED
L_ ,jil]y 1992 FI NA ,
4. TITLE AND SUBTITLE 5. FUNDING NUMBERS
] Ma J ,( ant- U
. O,..'• i.-'5: tu i ,Cl r nt: 6223 IN
P .)rogram Ele m2e1
Special Operations Personnel Work Unit Number:
6. AUTHOR•(S) MM33P30.002-6005

Paul Naitoh and Tamaln Kelly

7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION
Naval Health Research Center Report No. 92-28
P. 0. Box 85122
San Diego, CA 92186-5122
9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSORING/MONITORING
Naval Medical Research and Development Command AGENCY REPORT NUMBER
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Building 1, Tower 2
Bethoqria. MD) 20•H9-___44
11, SUPPLEMENTARY NOTES

12a. DISTRIBUTIONJAVAILABI LTY STATEMENT 12b. DISTRIBUTION CODE

Approved for public release; distribution is

unlimited.

13. ABSTRACT (Maximum 200 words)

The objective of sleep logist~ics• is Lo ensure that fiqhting men and women
at all levels obtain sufficient sleep to maintain combat. effertLiveriess
Special warfare miss3ions frequently involve night work and ardnous operot ioana
.schedni s. Th.is UnE•_r-'. C;uide expain a - selected sleep marnaqemncnt ,clmi uia
for u.e;• du r Lrii miliLar-y op)erat ions, witl) partL cular emplhasi.s on spr c .i.a1.
ope rat-ianr*
ii.in. mi [Thle Guido will at. flie d coirunandera in using. I ee}
locti.,' ics to )rEI,'eilt c"npromiqe of at J 3 In,ccompli-shimcnt dhin to .1 t',[)
depr i va ti on. In additiLon, it pr ovides.- tr.chn,i us• for as ;ean;111(1 :;ev er/ ty of
1001) dŽbt and a'omipon.-sat.inq f. or it i,j 1 ,1 ec ts.

14. SUBJECTTERMS 15. NUMBER OF PAGES

Sleep Management Sleep Logiticsr4
SI ee) Joss 16. PRICE CODE

17 SECURITY CLASSIFICA- 18. SECURITY CLASSIFICA- 19. SECURITY CLASSIFICA- 20. LIMITATION OF ABSTRACT
TION OF REPORT TION OF THIS PAGE "IONOF ABSTRACT
I nc I ass I f I v d lina I as:,s i f Ied lric I amus i I i e, 1in1 i t cd
I nm

NSN 7540-01-280-5500 Standard Form 298 (Rev. 2-89)

Proscribedby ANSI SOd. Z39- 18
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