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pdfU.S. Department of Transportation
Federal Motor Carrier Safety Administration
OMB Control Number: 2126-XXXX
Expiration Date:
MCSA-5864
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 2126-XXXX. Public reporting for this collection of information is
estimated to be approximately 30 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 and confidentiality will be provided to the extent
allowed by law. 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. 20590-0001.
FOLLOW UP SURVEY
Below are 41 life experiences you may have experienced recently. For each of the following
experiences, indicate to what degree it has been a part of your life OVER THE PAST MONTH.
1.
Disliking your daily activities
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
2. Disliking your work
_
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
3. Ethnic or racial conflict
Not at all part of my life
part of my life
Only slightly part of my life
Distinctly part of my life
Very much
4. Conflicts with in-laws or boyfriend’s/girlfriend’s family
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
5. Being let down or disappointed by friends
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
6. Conflict with supervisor(s) at work
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
7. Social rejection
Not at all part of my life
part of my life
Only slightly part of my life
Distinctly part of my life
Very much
8. Too many things to do at once
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
9. Being taken for granted
Not at all part of my life
part of my life
Only slightly part of my life
Distinctly part of my life
Very much
10. Financial conflicts with family members
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
11. Having your trust betrayed by a friend
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
12. Having your contributions overlooked
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
13. Struggling to meet your own standards of performance or accomplishment
Not at all part of my life
Only slightly part of my life
Distinctly part of my life
part of my life
Very much
14. Being taken advantage of
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
15. Not enough leisure time
Not at all part of my life
part of my life
Only slightly part of my life
Distinctly part of my life
Very much
16. Cash-flow difficulties _
Not at all part of my life
part of my life
Only slightly part of my life
Distinctly part of my life
Very much
17. A lot of responsibilities
Not at all part of my life
part of my life
Only slightly part of my life
Distinctly part of my life
Very much
18. Dissatisfaction with work
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
19. Decisions about intimate relationship(s)
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
20. Not enough time to meet your obligations
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
21. Financial burdens
Not at all part of my life
part of my life
Distinctly part of my life
Very much
22. Lower evaluation of your work than you think you deserve
Not at all part of my life
Only slightly part of my life
Distinctly part of my life
part of my life
Very much
23. Experiencing high levels of noise
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
24. Lower evaluation of your work than you hoped for
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
25. Conflicts with family member(s)
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
26. Finding your work too demanding
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
27. Conflicts with friends
Not at all part of my life
part of my life
Only slightly part of my life
Distinctly part of my life
Very much
28. Trying to secure loans
Not at all part of my life
part of my life
Only slightly part of my life
Distinctly part of my life
Very much
29. Getting “ripped off” or cheated in the purchase of goods
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
30. Unwanted interruptions of your work
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
Only slightly part of my life
31. Social isolation
Not at all part of my life
part of my life
Only slightly part of my life
Distinctly part of my life
Very much
32. Being ignored
Not at all part of my life
part of my life
Only slightly part of my life
Distinctly part of my life
Very much
33. Dissatisfaction with your physical appearance
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
34. Unsatisfactory housing conditions
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
35. Finding work uninteresting
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
36. Failing to get money you expected
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
37. Gossip about someone you care about
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
38. Dissatisfaction with your physical fitness
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
39. Gossip about yourself _
Not at all part of my life
part of my life
Only slightly part of my life
Distinctly part of my life
Very much
40. Difficulty dealing with modern technology
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
41. Hard work to look after and maintain home
Not at all part of my life
Only slightly part of my life
part of my life
Distinctly part of my life
Very much
Below are 18 statements about your opinions related to your work as a commercial driver.
Please read each statement and circle your response based on the following scale:
Circle: 1 for "Yes" if it describes your work
2 for "No" if it does not describe it
3 for "?" if you cannot decide
Think of your job in general as a commercial driver. All in all, what is it like most of the time?
For each of the following words or phrases, circle:
Yes
No
?
Pleasant ...................................
1
2
3
Bad..........................................
1
2
3
Ideal ........................................
1
2
3
Waste of time..........................
1
2
3
Good .......................................
1
2
3
Undesirable .............................
1
2
3
Worthwhile .............................
1
2
3
Worse than most .....................
1
2
3
Acceptable ..............................
1
2
3
Superior ..................................
1
2
3
Better than most......................
1
2
3
Disagreeable ...........................
1
2
3
Makes me content ...................
1
2
3
Inadequate...............................
1
2
3
Excellent .................................
1
2
3
Rotten .....................................
1
2
3
Enjoyable ................................
1
2
3
Poor.........................................
1
2
3
Please choose your response to each following question.
1. . Do you snore?
Yes
No
Don’t Know
If you snore, proceed to question 2. Otherwise, proceed to question 3.
2. Your snoring is:
Slightly louder than breathing
As loud as talking
. Louder than talking
. Very loud – can be heard in adjacent rooms
3. How often do you snore?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
4. Has your snoring ever bothered other people?
Yes
No
Don’t Know
5. Has anyone noticed that you quit breathing during your sleep?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
6. How often do you feel tired or fatigued after your sleep?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
7. During your waking time, do you feel tired, fatigued or not up to par?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
8. Have you ever nodded off or fallen asleep while driving a vehicle?
Yes
No
If you answered yes in question 8, proceed to question 91. Otherwise, proceed to question
10.
9. How often does this occur?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
10. Do you have high blood pressure?
Yes
No
Don’t Know
The following scale is used to determine the level of daytime sleepiness. How likely are you to
doze or fall asleep in the following situations? This refers to your usual way of life in recent
times. Even if you have not done some of these things recently, try to work out how they would
have affected you. Use the following scale for questions 1-8 to choose the most appropriate
number for each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
It is important that you answer each question as best you can.
Situation
1. Sitting and reading
2. Watching TV
3. Sitting, inactive in a public place (e.g. a
theatre or a meeting)
Chance of Dozing (0-3)
Situation
4. As a passenger in a motor vehicle for an
hour without a break
5. Lying down to rest in the afternoon when
circumstances permit
6. Sitting and talking to someone
7. Sitting quietly after lunch (no alcohol)
8. In a motor vehicle, while stopped for a
few minutes in traffic
Chance of Dozing (0-3)
| File Type | application/pdf |
| Author | lmarburg |
| File Modified | 2012-05-09 |
| File Created | 2012-05-09 |