Shipper and Carrier Particapant Questions

Shipper and Carrier Pilot Test Volunteers

Page #1

PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT
According to the Paperwork Reduction Act of 1995, a Federal agency may not conduct or sponsor, and a person is not required to
respond to, nor shall a person be subject to a penalty for failure to comply with, a collection of information unless it displays a current
valid OMB control number. The valid OMB control number for this information collection is 2137-0034. The information requested on
this form is being collected by the U.S. Department of Transportation, Pipeline and Hazardous Materials Safety Administration
(PHMSA). Public reporting burden for this collection of information is estimated to be 30 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. All responses to this collection are voluntary. Send comments regarding this burden estimate or any
other aspect of the collection of information, including suggestions for reducing this burden, to: Mr. T. Glenn Foster, Information
Collection Clearance Officer, U. S. Department of Transportation, PHMSA, Office of Hazardous Materials Safety, PHH-10, 1200
New Jersey Ave., S.E., 2nd Floor East, E24-301, Washington, DC 20520.

Page #2
 Question 1
Name of company/organization:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
 Question 2
Point(s) of contact (POC(s)) information:
Name of POC for pilot tests and orientation meeting:

______________________

Title:

______________________

Address:

______________________

Phone:

______________________

Email:

______________________

Name of company/organization POC (if different than POC listed above):

______________________

Title:

______________________

Address:

______________________

Phone:

______________________

Email:

______________________

 Question 3
Is your company/organization a shipper, a carrier, or both?
 Shipper
 Carrier
 Both shipper and carrier
 Neither, please explain how your company/organization qualifies as a shipper or carrier participant: __________________________

Page #3
Simple Skipping Information
   • If Question 4 = No then Terminate survey
 Question 4
Is your company/organization willing to participate in the pilot tests for a period of 8 to 12 weeks in 2014 (specific period to be
determined)?
 Yes
 No

Page #4
Simple Skipping Information
   • If Question 5 = No then Terminate survey
 Question 5
Does your company/organization understand that answering these selection questions does not guarantee your
company/organization will be selected for participation in the pilot tests (volunteers will be selected based on meeting qualifications
specified in MAP-21 and the ability to aid in testing a variety of test scenarios and criteria)?
 Yes
 No

Page #5
Simple Skipping Information
   • If Question 6 = No then Terminate survey
 Question 6
Is your company/organization able to identify a single POC for coordinating your company’s/organization’s participation in the pilot
tests?
 Yes
 No

Page #6
Simple Skipping Information
   • If Question 7 = No then Terminate survey
 Question 7
Is your company/organization willing to provide a coordinating representative to participate in a webinar-based pre-pilot coordination
and training meeting prior to implementation of the pilot tests?
 Yes
 No

Page #7
Simple Skipping Information
   • If Question 10 = No then Terminate survey
 Question 8
Is your company/organization willing to provide a coordinating representative to participate in a one-day webinar-based debriefing
meeting following the conclusion of the pilot tests (actual date to be determined)?
 Yes
 No
 Question 9
Does your company/organization have videoconference capability?
 Yes
 No
 Question 10
Is your company/organization willing to allow, and participate in, inspections and emergency response simulations during the pilot
tests?
 Yes
 No

Page #8
Simple Skipping Information
   • If Question 11 = No then Terminate survey
 Question 11
Is your company/organization willing to provide feedback on its experiences regarding paperless hazardous materials (e-HM)
communication during the pilot tests, including actual e-HM communications data from your company’s/organization’s participation in
the pilot tests and information on administrative, business, training, equipment, and operational-related costs and benefits
associated with implementing e-HM systems?
 Yes
 No

Page #9
 Question 12
Do you understand that PHMSA will use the information you provide in this questionnaire as part of PHMSA’s public report to
Congress, Federal agencies, and other stakeholders, in support of the Moving Ahead for Progress in the 21st Century Act
(MAP-21)?
 Yes
 No
 Question 13
For which U.S. geographic pilot test area(s) is your company/organization volunteering to participate? Please select all that apply:
 Northeast
 Northwest
 Southeast
 Southwest
 Question 14
Do any of your company’s/organization’s HM shipments that could be included in the pilot tests cross international borders during
transport (U.S. and Canadian border, U.S. and Mexican border, travel via plane or ship to other international locations)?
 Yes
 No
 Question 15
Please describe the transport route(s), from origin to final destination, for the HM your company/organization will include in the pilot
tests. Include city and state information, along with the general location(s) of any planned stops/layovers, including transfer points.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Page #10
Simple Skipping Information
   • If Question 18 = No then Terminate survey
Branching Information
 Question 16
Does your company/organization utilize an outside company to assist with HM information and emergency response
communication?
 Yes, please provide the name of the company: __________________________
 No
 Question 17
Has your company/organization ever used wireless or electronic communication to provide law enforcement or emergency response
personnel with HM information for an HM shipment involved in an inspection or incident?
 Yes
 No
 Question 18
Does your company/organization currently have a paperless HM communications system (e-system) capable of managing and
communicating the HM shipping paper information?
 Yes
 No

Page #11
Branching Information
 Question 19
How many different e-systems is your company/organization capable of utilizing for communicating HM shipping paper information?
 One
 Two
 Three or more
 Question 20
What electronic and wireless technology(ies) are used by your e-system? Please select all that apply:
 Personal digital assistants (PDAs)
 Vehicle laptops
 Workplace computers
 Computer aid dispatch (CAD) terminals
 Home computers
 Landline telephones
 Cellular telephones
 Smartphones
 Videos
 Facsimile (FAX) machines
 Live web cameras
 Pagers
 Two-way radios
 Walkie-talkies
 Tablets
 Other, please identify: __________________________
 Question 21
What type of electronic data exchange format is used by your e-system? Please select all that apply:
 Extensible Markup Language (XML)
 Universal Business Language (UBL)
 Electronic Data Interchange (EDI)
 United Nations/Electronic Data Interchange For Administration, Commerce and Transport (UN/EDIFACT)
 Other, please specify: __________________________
 Question 22
In what format(s) can your e-HM shipping paper information be exported? Please select all that apply:
 Portable Document Format (pdf)
 Tagged Image File Format (tiff)
 Joint Photographic Experts Group (jpeg)
 Other, please specify: __________________________
 Question 23
Is your company’s/organization’s e-system scalable (i.e., able to expand if the amount of information increases)?
 Yes
 No
 Question 24
Does the e-system have built-in security protocols for data protection?
 Yes
 No
 Question 25
Has your company/organization established administrative rights for the e-system?

 Yes
 No
 Question 26
Does the e-system have system redundancy or backup systems?
 Yes
 No
 Question 27
Can e-HM shipping information be accessed during transport (in the field) in real-time?
 Yes
 No

Page #12
Branching Information
   • If not Question 31 = Yes then Hide 31a. What type(s) of intermodal carriers does you...
   • If Question 31 = No then Disable 31a. What type(s) of intermodal carriers does you...
 Question 28
What class(es) of HM would your company/organization ship during the pilot tests? Please select all that apply:
 Class 1 Explosives
 Class 2 Gases
 Class 3 Flammable Liquids (100°F or less, closed cup)
 Class 4 Other Flammable Substances
 Class 5 Oxidizing Substances and Organic Peroxides
 Class 6 Toxic (Poisonous) and Infectious Substances
 Class 7 Radioactive Materials
 Class 8 Corrosives
 Class 9 Miscellaneous Dangerous Materials
 Question 29
Is your company/organization willing to include multiple shipments in the pilot tests?
 Yes
 No
 Question 30
By what mode(s) would your company/organization transport HM during the pilot tests? Please select all that apply:
 Roadway (truck)
 Rail
 Air
 Maritime (vessel)
 Question 31
Does your company/organization interact with intermodal carriers for HM transfers?
 Yes
 No
 31a. What type(s) of intermodal carriers does your company interact with for HM transfers? Please select all that apply:
 Roadway (truck)
 Rail
 Air
 Maritime (vessel)
 Question 32
Is your company/organization capable of testing less than truckload (LTL) HM shipments during the pilot tests?
 Yes
 No
 Question 33
Does your company/organization transport HM shipments utilizing your own equipment and personnel or contractor resources?
 Only company/organization equipment and personnel
 Only contractor resources
 Both company/organization equipment and personnel AND contractor resources
 Question 34
Does your company/organization interact with freight forwarders and/or brokers as part of your normal business of transporting HM
shipments?

 Yes
 No