OMB
NO: XXXX-XXXX
EXPIRATION
DATE: mm/dd/yyyy
Participant ID: _________
Public Burden Statement
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 subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is XXXX-XXXX. Public reporting for this collection of information is estimated to be approximately 5 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.
Flexible Sleeper Berth – Background Questionnaire
Information
on this form will be kept confidential within the research team
and
will not be shared with your company.
Please answer all questions as accurately as possible.
What is your age? _________ years
Gender: ☐ Male ☐ Female
How tall are you? ______ feet _____ inches
What is your weight? ____________ pounds (lbs)
Years of commercial driving experience ____________ years
Do you have a million miler safety record? ☐ Yes ☐ No
If yes: ☐ 1 million miles ☐ 2 million miles ☐ 3 million miles
Have you taken any modules from the North America Fatigue Management Program? ☐ Yes ☐ No
If yes, check all that apply:
☐ Module 1: FMP Introduction and Overview
☐ Module 2: Safety Culture and management Practices
☐ Module 3: Driver Education
☐ Module 4: Driver Family Education
☐ Module 5: Train-the-Trainer for Driver Education and Family Forum
☐ Module 6: Shippers and Receivers
☐ Module 7: Motor Carrier Sleep Disorders Management
☐ Module 8: Driver Sleep Disorders Management
☐ Module 9: Driver Scheduling and Tools
☐ Module 10: Fatigue Monitoring and Management Technologies
How long have you worked at your present company? _______years _______months
Type of driver: ☐ Day ☐ Night ☐ Mixed
What is your home terminal time zone used for HOS logs?
☐ Eastern ☐ Central ☐ Mountain ☐ Pacific
What is your driving type?
☐ Local ☐ Regional ☐ Over-The-Road
What is your operational type?
☐ Intermodal ☐ Dedicated
☐ Flatbed ☐ Temperature control
☐ Van truckload ☐ Other, please specify _____________________
What type of CDL endorsement/restrictions do you have? (Check all that apply.)
☐ Air brakes restriction (L) ☐ Intrastate only (K)
☐ Passenger (P) ☐ Double/triple trailer (T)
☐ Tank (N) ☐ HazMat (H)
☐ Tank and HazMat (X) ☐ Other, please specify _____________________
What type of trailer do you typically use?
☐ Dry Van (Box Trailer) ☐ Flatbed Trailer ☐ Tank Trailer (Tanker)
☐ Refrigerated Trailer ☐ Specialized Trailer
Is your truck equipped with any of the following? (Check all that apply.)
☐ Auxiliary Power Unit ☐ Espar Heater
☐ Optimized Idle ☐ Other Idle Reduction Technology: ______________________
Do you ever use platooning? ☐ Yes ☐ No
Do you wear contact lenses? ☐ Yes ☐ No
Do you wear glasses when driving? ☐ Yes ☐ No
Has a physician informed you that you have any of the following conditions? (Mark all that apply to you.)
☐ Sleep apnea ☐ Diabetes
☐ High blood pressure ☐ Insomnia
Do you use any of the following? (Mark all that apply to you)
☐ CPAP for sleep apnea ☐ Medication for diabetes
☐ Medication for high blood pressure ☐ Medication for insomnia
How often do you experience pain of any kind during a typical daily work shift? (Check only 1 box)
☐ 0–5% of shift ☐ 5–25% of shift ☐ 25–50% of shift ☐ 50–75% of shift ☐ 75% or more of shift
Do you typically consume caffeine?
☐ No ☐ Yes (If yes, for all categories that apply, indicate amount consumed in a typical day.)
Coffees _______ cups per day Cola drinks _______ drinks per day
Energy drinks _______ drinks per day Caffeine pills _______ pills per day
Caffeine gum _______ sticks/pieces per day Tea (not herbal) _______ cups per day
Do you typically use tobacco or nicotine products?
☐ No ☐ Yes (If yes, for all categories that apply, indicate amount used in a typical day.)
Cigarettes _______ cigarettes per day Cigars _______ cigars per day
Chew tobacco _______ pinches/pouches per day Smoke pipe _______ bowls per day
Nicotine
gum _______ sticks/pieces per day E-cigarettes _______ mL per day
(w/nicotine)
_______mg nicotine per mL
Thank you!
Page
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | DRIVER INFORMATION FORM |
| Author | Honn, Kimberly |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |