MCSA-5863 Commercial Motor Vehicle Driver Survey

U.S. Department of Transportation
Federal Motor Carrier Safety Administration
MCSA-5863

OMB Control Number: 2126-XXXX
Expiration Date:

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 60 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.

Commercial Motor Vehicle Driver Survey
Employee #__________________
Date: __________________
Questionnaire #1
Please respond to the following questions by either placing an “X” in the appropriate box or
writing a clear answer in the space provided. There are no “correct” responses, please just be
honest. REMEMBER, you are only able to participate if you have completed driver
orientation at your current fleet WITHIN THE LAST YEAR. You will not be compensated
for your participation if this is not true for you.
1. Please mark your marital status (please check).
Single
i.

Married

Divorced

Widowed

If married, how long have you been married in years? ______

2. Do you have any children [include step-children] (please check).
i.

Yes

No

If yes, how many children live at home with you?_____

3. How many years of school have you completed? [e.g., High school diploma = 12,
Associates Degree = 14, Bachelors Degree = 16] ___________years.
4. What is the highest academic degree you have earned (please check one)?
GED
High School Diploma
Associate’s Degree
Bachelor’s Degree
Master’s Degree
Doctorate
MD
None of the above
1

5. Is English your primary language (please check)?
i.

Yes

No

If no, please indicate your primary language here__________________

6. How long have you been driving commercial vehicles? _____years _____months
7. Please give the type of trucking license(s) you currently hold _______________
8. Type of truck endorsements held (please check all that apply):
Hazardous Materials
Tanker Vehicle
Bus Passenger
School Bus
9. Are you an owner operator?

Yes

Double/Triple Trailers
Combination HazMat/Trailer
Other _______________

No

10. When driving your personal vehicle, how often do you wear a seat belt (please check)?
Always
Often
Sometimes
Rarely
Never
11. When driving a commercial vehicle, how often do you wear a seat belt (please check)?
Always
Often
Sometimes
Rarely
Never
12. Over the past three years, have you had any crashes in any vehicle, either personal or
commercial [also include any crash reported to police, insurance company, and/or carrier]
(please check)?
Yes
No (if no, skip to question 15)
i.

If yes, check the type of vehicle, fault status, and crash type/role code (using the
below codes 1-13) for each crash over the past three years. Each row is a
different crash: thus, if you had two crashes you would complete two rows, one
for each crash:

Crash Type/Role Codes
(1) Roadside Departure
(2) Rear-end
(3) Side-swipe
(4) Hit Fixed Object

Commercial
Vehicle

Personal
Vehicle

(5) Hit Moving Object
(6) Backing
(7) Parking Lot
(8) Roll-over

At-Fault

Not AtFault

1.
2.
3.
4.
2

(9) Jacknife
(10) T-bone
(11) Head-on
(12) Pedestrian
(13) Other

Crash Type/Role (Code)

5.
6.
7.
13. Over the past three years, have you had any moving violations in any vehicle, either
personal or commercial (please check)?
Yes
No (If no, skip to question 16)
i.

If yes, check the type of vehicle and violation type (e.g., speeding, tailgating,
signal violation), for each crash over the past three years. Each row is a different
violation: thus, if you had two violations you would complete two rows, one for
each violation:

Commercial Vehicle

Personal Vehicle

Violation Type

1.
2.
3.
4.
5.
6.
7.

14. Over the past three years, have you been put out-of-service in any roadside inspection(s)
(please check)?
Yes (list the vehicle and driver violations below)
i.

No (If no, skip to question 17)

If yes, list the vehicle (e.g., brakes, tires, etc.) and/or driver (e.g., hours-of-service,
log violation, etc.) out-of-service violation. Each row is a different violation: thus,
if you had two violations you would complete two rows, one for each violation:
Vehicle Violation
1.
2.
3.
4.
5.
6.
7.

Driver Violation
1.
2.
3.
3

4.
5.
6.
7.
15. Have you attended a formal truck driver training school prior to your current training
(please check)?
Yes
No
i.

If yes, how long was the training you received, in weeks/days (please check)?
Weeks
0
1
2
3
4
5
6
7
8

Days
0
1
2
3
4
5
6

16. Prior to your first commercial driving job, did you receive any other commercial driver
training? This includes informal training such as a friend or relative teaching you how to
drive a truck (please check).
Yes
i.

No
If yes, how long was the training? Please indicate length in hours, days, or weeks,
whatever is appropriate.
How many weeks? __________
How many days if less than a week? __________
How many hours if less than a day? __________

17. How much on-the-job training have you received? Please indicate whether it was hours,
days or weeks in your answer. ________________________
18. Do you usually nap during the day (or between major sleep periods)? [Note: Naps may be
of any duration] (please check).
Yes
No
19. Do you drink coffee or other caffeinated beverages or energy supplements (e.g., tea, Coke,
Pepsi, Mountain Dew, Red Bull, No Doz, etc.) (please check)?
Yes
No
i.

If yes, please list how many cups/glasses/pills per day (e.g., 2 cups of coffee).
________________________

4

20. Do you drink alcohol (please check)?
i.

Yes

No

If yes, how many days a week (please check)?
1
2
3
4
5
6
7

ii.

If yes, how many alcoholic drinks do you average in a week? ____________
drinks per week

21. Do you currently smoke cigarettes or use other tobacco products (please check)?
Yes
No
22. When you are not working, do you find time to exercise (please check)?
i.

Yes

No

If yes, how many times per week do you engage in at least moderate intensity
exercise (such as brisk walking) for a minimum of 30 minutes (please check)?
1
2
3
4
5
6
7
More than 7

23. How would you describe your diet (please check)?
Poor
Below Average
Average
24. In general, do you keep a regular sleep schedule?

Above Average
Yes

Sometimes

Excellent
No

25. Overall, about how many hours of actual sleep do you usually get in a 24-hour period
(please check)?
1
2
3
4
5
6

7
8
9
10
11
12

13
14
15
16
17
18
5

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 26-33 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

Chance of Dozing (0-3)
____

26. Sitting and reading
27. Watching TV

____

28. Sitting, inactive in a public place (e.g. a
theatre or a meeting)

____

29. As a passenger in a motor vehicle for an
hour without a break

____

30. Lying down to rest in the afternoon
when circumstances permit

____

31. Sitting and talking to someone

____

32. Sitting quietly after lunch (no alcohol)

____

33. In a motor vehicle, while stopped for a
few minutes in traffic

____

Please choose your response to each following question.
34. Do you snore?

Yes

No (skip to #38)

If you snore:
35. Your snoring is:
Slightly louder than breathing
As loud as talking
. Louder than talking
. Very loud – can be heard in adjacent rooms

6

Don’t Know

36. 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
37. Has your snoring ever bothered other people?
Yes
No
Don’t Know
38. 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
39. 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

40. 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
41. Have you ever nodded off or fallen asleep while driving a vehicle?
Yes
No
If you answered yes in question 41, proceed to question 42. Otherwise, proceed to question
43.
42 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
43. Do you have high blood pressure?

Yes
7

No

Don’t Know

Questionnaire #2
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
by marking an “X” in the column under your response. There are no “correct” responses, please
answer honestly.

1. Disliking your daily activities over the past month.
2. Disliking your work over the past month.
3. Ethnic or racial conflict over the past month.
4. Conflicts with in-laws or boyfriend’s/girlfriend’s family
over the past month.
5. Being let down or disappointed by friends over the past
month.
6. Conflict with supervisor(s) at work over the past month.
7. Social rejection over the past month.
8. Too many things to do at once over the past month.
9. Being taken for granted over the past month.
10. Financial conflicts with family members over the past
month.
11. Having your trust betrayed by a friend over the past
month.
12. Having your contributions overlooked over the past
month.
13. Struggling to meet your own standards of performance
or accomplishment over the past month.
14. Being taken advantage of over the past month.
15. Not enough leisure time over the past month.
16. Cash-flow difficulties over the past month.
8

17. A lot of responsibilities over the past month.
18. Dissatisfaction with work over the past month.
19. Decisions about intimate relationship(s) over the past
month.
20. Not enough time to meet your obligations over the past
month.
21. Financial burdens over the past month.
22. Lower evaluation of your work than you think you
deserve over the past month.
23. Experiencing high levels of noise over the past month.
24. Lower evaluation of your work than you hoped for over
the past month.
25. Conflicts with family member(s) over the past month.
26. Finding your work too demanding over the past month.
27. Conflicts with friends over the past month.
28. Trying to secure loans over the past month.
29. Getting “ripped off” or cheated in the purchase of goods
over the past month.
30. Unwanted interruptions of your work over the past
month.
31. Social isolation over the past month.
32. Being ignored over the past month.
33. Dissatisfaction with your physical appearance over the
past month.
34. Unsatisfactory housing conditions over the past month.
35. Finding work uninteresting over the past month.
9

36. Failing to get money you expected over the past month.
37. Gossip about someone you care about over the past
month.
38. Dissatisfaction with your physical fitness over the past
month.
39. Gossip about yourself over the past month.
40. Difficulty dealing with modern technology over the past
month.
41. Hard work to look after and maintain home

10

Questionnaire #3
Below are 38 questions about your driving. Please note the rating scale has changed from the
previous section. Read each item and choose your response by marking an “X” in the column
under your response. There are no “correct” responses. Please answer honestly.

1. I drive when I am angry or upset.
2. I lose my temper when driving.
3. I consider the actions of other drivers to be
inappropriate or “stupid.”
4. I flash my headlights when I am annoyed by
another driver.
5. I make rude gestures (for example, giving the “finger”
or yelling curse words) toward drivers who annoy me.
6. I sometimes feel resentful when I don’t get
my own way.
7. I verbally insult drivers who annoy me.
8. I deliberately use my car/truck to block drivers who
tailgate me.
9. If another driver seriously threatens my safety, I would
defend myself.
10. I would tailgate a driver who annoys me.
11. I sometimes try to get even rather than forgive and
forget.
12. I “drag race” other drivers at stop lights to get out
front.
13. I will illegally pass a car/truck that is going too slowly.
14. I am always willing to admit when I’ve made a
mistake.
15. I feel it is my right to strike back in some way, if I feel
another driver has been aggressive toward me.
16. When I get stuck in a traffic jam I get very irritated.
17. I will race a slow moving train to a railroad crossing.

11

18. I have sometimes taken unfair advantage of another
person.
19. I will weave in and out of slower traffic.
20. I will drive if I am only mildly intoxicated or buzzed.
21. When someone cuts me off, I feel I should punish
him/her.
22. I get impatient and/or upset when I fall behind
schedule when I am driving.
23. I am always courteous, even to people who are
disagreeable.
24. Passengers in my car/truck tell me to calm down.
25. I get irritated when a car/truck in front of me slows
down for no reason.
26. I will cross double yellow lines to see if I can pass a
slow moving car/truck.
27. I feel it is my right to get where I need to go as quickly
as possible.
28. I am an aggressive driver.
29. I feel that passive drivers should learn how to drive or
stay home.
30. I keep some type of weapon in my car/truck.
31. I am always a good listener, no matter who I’m talking
to.
32. I will drive in the shoulder lane or median to get
around a traffic jam.
33. When passing a car/truck on a 2-lane road, I will
barely miss on-coming cars.
34. I will drive when I am drunk.
35. I feel that I may lose my temper if I have to confront
another driver.
36. I consider myself to be a risk-taker.
37. I feel that most traffic “laws” could be considered as
suggestions.
38. There have been occasions when I have taken
advantage of someone.
12

Questionnaire # 4
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
JOB IN GENERAL
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:

Pleasant...................................
Bad .........................................
Ideal ........................................
Waste of time .........................
Good .......................................
Undesirable.............................
Worthwhile.............................
Worse than most.....................
Acceptable ..............................
Superior ..................................
Better than most .....................
Disagreeable ...........................
Makes me content...................
Inadequate ..............................
Excellent.................................
Rotten .....................................
Enjoyable................................
Poor ........................................

13

Yes
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

No
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

?
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3