2 Screen Shot Survey $10 Incentive

ATTACHMENT C:

Screen shots of Drugged Driving Survey (DDS)
with $10 incentive

NIDA

Drug Driving Survey
Age Verification
Page description:
Form Approved OMB No. 0925-XXXX
Expiration Date 00/00/20XX
Burden Statement: Public reporting burden for this collection of information is estimated to
average 12 minutes per response. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to: NIH, Project
Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA
(0925-XXXX).

This anonymous survey is designed for people who are 18 years of age or older. If you are not
18 years old or over, you are not eligible. Before proceeding please certify that you are 18 years
or older:

1. I am 18 years of age or older. *
Yes, I am 18 years of age or older.
No, I am not 18 years of age or older.

2. You received a sticker on your receipt from your state or jurisdiction’s Department of Motor
Vehicles. Please enter the code you received on your sticker.

Basic Information

Page description:
Background: The Drugged Driving Survey asks questions about medications, drugs, alcohol,
and driving and is designed to understand more about drugged driving. The information
gathered in this survey will be used for research on drugged driving. We want to know about
what medications or drugs people may have taken that could possibly impair their ability to
drive safely. You will be asked information about your personal use of medications, drugs,
alcohol and driving.
THIS SURVEY IS COMPLETELY ANONYMOUS – we will not ask you to provide any
information that could identify you as an individual or the computer that you used to complete
the survey. You will be asked some information about yourself such as age, gender, and zip
code, but you will not be asked your name or any other personally identifying information. Even
though the survey is anonymous, your responses will stored in a secure facility – that means we
will keep your responses secure, and will not share or report any individual survey responses,
only grouped (aggregated) information (e.g. “women who are between 18-24 reported that…” or
“men reported that....”)

When you complete the survey, you will get a code for a $10 gift card. Using this code, you will
be able to go to: http://www.ngc-group.com/ and select from more than 70 retail or restaurant gift
cards.

Driving background
Page description:
This survey asks questions about driving motor vehicles such as cars, SUVs, vans,
motorcycles, and trucks of all sizes (e.g., light, medium, heavy, very heavy, transporters) that are
driven on roads and highways. It does not refer to “off-road” vehicles.

3. Please tell us if you have driven a motor vehicle in: *
Yes
Past 30 days *

No

4. Have you driven a motor vehicle in: *
Yes

No

The past year

5. What type of license(s) do you have? Check all that apply. *
State issued driver’s license (this includes learners permit, provisional and/or special
licenses for new drivers)
State Issued commercial driver’s license (CDL) (i.e., to drive a commercial vehicle
based on your state or jurisdiction regulations for commercial vehicles)
State issued motorcycle license
I drive, but I don’t have a license OR my license is suspended, revoked, or expired

6. On average, about how many miles do you think you drive each year? *
Less than 8,000 miles per year (less than 667 per month)
8,000 to 15,000 (between 668 and 1,250 per month)
15,000 to 20,000 (between 1,251 and 1,667 per month)
More than 20,000 (more than 1,668 per month)

Demographics
Page description:

7. What is your current age in years? *

8. Are you male or female? *
Male
Female

9. What is the zip code for your place of residence? *

10. What is the highest grade or year of school you have completed? *
Never attended school
Kindergarten – 8th grade
Some high school – no degree
High school graduate
High school equivalency (sometimes known as “GED”)
Trade school (e.g., certification program for electrician) following high school
Some college – no degree
Associate’s degree
Bachelor’s degree
Master’s degree
Doctoral degree

11. Are you still in school? If YES, please indicate the type of school from the choices below: *
NO, I am not in school.
YES, I am in high school.
YES, I am in college or graduate school.
YES, I am in a training or technical program.

12. What is your present job status? Please pick one: *
Working
Unemployed and looking for work
Disabled and unable to work
Retired
Homemaker
Other

13. If you are working now, are you working (please check one):
Full time
Part time

14. Are you now, or have you ever been, in the U.S. military? *
Yes
No

15. Please check the status that applies for your military status:
Active Duty
Active Reserve or National Guard
Inactive Reserves
Separated
Retired

16. Which races best describe you? (Please select all that apply) *
American Indian
Asian
Black or African American
White
Native American
Native Hawaiian or other Pacific Islander

17. Which ethnicity best describes you? (Select only one) *
Hispanic or Latino
Not Hispanic or Latino

Driving Incidents

Page description:
This next section asks questions about driving experiences where you came very close to
having an accident/crash. (e.g. this includes a near collision with one or more other vehicles,
whether moving or parked; an object (tree, guardrail, etc.); bicyclist; or pedestrian.) Remember
this survey is completely anonymous. The information you provide will only be used for
research purposes.

18. During the past 30 days, have you had any experiences where you came very close to
having an accident/crash? *
Yes
No

19. When you think back to that experience, what may have contributed to coming very close to
having an accident/crash? Check all that apply.
The weather was bad (e.g., heavy rain, fog, snow, or other bad weather conditions)
I was sleepy or had fallen asleep
Another driver caused the near accident/crash
Distracted (e.g. texting, using cellular phone, etc.)
I had been drinking alcohol prior to driving
I had taken prescription medication prior to driving
I had taken an over-the-counter drug prior to driving
I had used marijuana prior to driving
I had taken illegal drugs (other than marijuana) prior to driving
I had been drinking alcohol prior to driving and taken a medication or drug

Citations for moving violations

Page description:
Here is some background information about the next section: A citation for a moving violation is
when you receive a ticket or other official citation for any alleged violation of the law when you
are the driver of a vehicle while it is moving. Examples of moving violations include: running a
stop sign or red traffic light; speeding, which can be exceeding a limit or simply driving an
unsafe speed; failure to signal for turns or lane changes, reckless driving, or driving under the
influence. Different states and jurisdictions have different names for driving while under the
influence of drugs or alcohol, including driving while impaired or intoxicated (DWI), driving
under the influence of alcohol or drugs (DUI), operating while intoxicated or impaired (OWI), or
operating under the influence of alcohol or drugs (OUI). Remember this survey is completely
anonymous. The information you provide will only be used for research purposes. Please select
one of the following options.

20. In the past year, did you receive any citations/tickets for any alleged moving violations?
(See above for information about moving violations.) *
YES, I did receive a citation for a moving violation
NO, I did not receive a citation for a moving violation.

21. You answered “yes” to the previous question about receiving a citation for a moving
violation in the past year. Please give us additional information about your alcohol or
medication/drug use prior to the citation for a moving violation even though you might not have
been cited or arrested specifically for the use of substances that can impair driving.
Remember this survey is completely anonymous. The information you provide will only be used
for research purposes. Please select one of the following options.
I had been drinking alcohol prior to the citation for a moving violation.
I had taken medications or used drugs prior to the citation for a moving violation.
I had combined alcohol with medications or drugs prior to the citation for a moving
violation.
I had NOT taken or used medications, drugs, or alcohol prior to the citation for a moving
violation.

22. In the past year, were you involved in an accident/crash while you were driving? *
YES, I was involved in an accident/crash with another vehicle in the past year.
YES, I was involved in an accident/crash in the past year, but there were no other
vehicles involved.
NO, I have not been involved in any accidents/crashes in the past year.

23. You answered “Yes” that you were involved in an accident/crash in the past year. Please
give us additional information about your accident/crash. Check all that apply.
I had been drinking alcohol prior to the accident/crash.
I had taken medications or used drugs (legal or illegal) prior to the accident/crash.
I had been drinking alcohol and taken medications or used drugs prior to the
accident/crash.
I had NOT been drinking alcohol, taking medications, or using drugs prior to the
accident/crash.

ALCOHOL, DRUGS AND OVER-THE-COUNTER MEDICATION
Page description:
ALCOHOL, OVER-THE-COUNTER MEDICATIONS, AND DRUGS
This section of the survey is focused on the use of alcohol, drugs, and medications that may
have an effect on someone’s ability to drive safely. It includes questions about alcohol and a
variety of drugs, medications, and marijuana. Remember this survey is completely anonymous.
The information you provide will only be used for research purposes.

24. ALCOHOL *
YES, I have used
this in the past 30
days

NO, I have not used
this in the past 30
days

Alcohol: Includes wine, beer, spirits, and
other drinks containing alcohol/liquor. *

25. OVER-THE-COUNTER MEDICATIONS/DRUGS *
YES, I have
used this in the
past 30 days
Over-the-counter sleep aids: Often contains
antihistamines (e.g., Unisom or Tylenol P.M.)
Over-the-counter cold/allergy medicines: Often
contains antihistamines such as
Diphenhydramine (e.g., Benadryl)
Over-the-counter cough suppressant medicines:
Often contains Dextromethorphan (DM) (e.g.,
Robitussin)

NO, I have not
used this in the
past 30 days

26. MARIJUANA *
YES, I
have
used
this in
the
past
30
days
Marijuana or Hashish: Used for recreational and/or medicinal
purposes even if medicinal or recreational use of marijuana is not
legal in your state or jurisdiction. This refers to smoking
marijuana/hashish, or eating or drinking products containing
marijuana/hashish (consuming marijuana-infused food products, also
known as "edibles". *

NO, I
have
not
used
this in
the
past 30
days

27. DRUGS *
YES,
I
have
used
this in
the
past
30
days

NO, I
have
not
used
this in
the
past
30
days

Spice/K2/Herbal Incense. "Spice" or “K2” refers to a wide variety of
herbal/spice/plant mixtures that are sprayed with a chemically similar
to marijuana. Sometimes it is referred to as “synthetic cannabis” or
“synthetic marijuana.” Other street names: Fake Weed, Yucatan Fire,
Skunk, Moon Rocks, Mojo, Cloud 9, Smacked! Black Mamba, Bliss,
Bombay Blue, Genie, or Zohai.) *
Bath Salts (These are not salts that you put in a bath. They are drugs
designed to make you “high.” These drugs contain chemicals
(synthetic cathinones) which are amphetamine-like stimulants.) *
Inhalants: Includes use of glue, correction fluid, nitrous oxide, or
‘whippits,’ etc. *
Cocaine (e.g., inhaled, injected, crack, freebase) *
Amphetamines (e.g., Meth, Ecstasy, MDMA) *
Heroin *
PCP (e.g., angel dust) *
Hallucinogens (e.g., LSD/Acid, Mushrooms, Ketamine) *
Other illegal drugs not on this list *

Prescription Medications
Page description:
This survey is focused on the use of alcohol, drugs, and medications that may have an effect on
someone’s ability to drive safely. This section of the survey asks about your use of prescription
medicines. We are not talking about prescription medications such as antibiotics, cholesterollowering medications, or other commonly prescribed medications. Remember this survey is
completely anonymous. The information you provide will only be used for research purposes.

28. PAIN RELIEVERS *
YES,
I
have
taken
this
in the
past
30
days

NO, I
have
not
taken
this in
the
past
30
days

Pain Relievers: These are sometimes called “pain killers.” Examples of
pain relievers include: Morphine, Codeine, combinations of
Hydrocodone/Acetaminophen (e.g., Vicodin, Percocet); Oxycodone
(e.g., OxyContin); Demerol, Dextropropoxyphene (e.g.,
Darvocet/Darvon); Ultram (e.g., Tramadol and other pain relievers); or
Fentanyl and synthetic opioid painkillers (e.g., Actiq, Duragesic, and
Sublimaze) *

29. You have answered “yes” to having taken pain relievers in the past 30 days. Do you have a
prescription for this medication?
YES, I have a prescription for this medication
NO, I do not have a prescription for this medication

30. Sedatives or Tranquilizers *
YES, I
have
taken
this in
the past
30 days

NO, I
have not
taken this
in the
past 30
days

Sedatives or Tranquilizers: Barbiturates (e.g., Phenobarbital);
Benzodiazepines or other tranquilizers (e.g., Diazepam, Valium);
Alprazolam (e.g., Xanax); Chlordiazepoxide HCl (e.g., Librium);
Estazolam (e.g., ProSom); Clonazepam (e.g., Klonopin); or
others *

31. You have answered “yes” to having taken sedatives or tranquilizers in the past 30 days. Do
you have a prescription for this medication?
YES, I have a prescription for this medication
NO, I do not have a prescription for this medication

32. Sleep Medications *
YES, I have
taken this in
the past 30
days
Sleep Medications: Prescription sleeping pills such as
Zolpidem (e.g., Ambien); Zaleplon (e.g., Sonata); and
Eszopiclone (e.g., Lunesta) or other sleeping pills *

NO, I have not
taken this in
the past 30
days

33. You have answered “yes” to having taken sleep medications in the past 30 days. Do you
have a prescription for this medication?
YES, I have a prescription for this medication
NO, I do not have a prescription for this medication

34. Muscle Relaxers *
YES, I have
taken this in
the past 30
days

NO, I have not
taken this in the
past 30 days

Muscle Relaxers: Common types are Caclofen;
Tizanidine (e.g., Zanaflex); Carisoprodol (e.g.,
Soma) or other muscle relaxers *

35. You have answered “yes” to having taken muscle relaxers in the past 30 days. Do you have
a prescription for this medication?
YES, I have a prescription for this medication
NO, I do not have a prescription for this medication

36. Anti-depressants
YES, I
have
taken this
in the
past 30
days

NO, I have
not taken
this in the
past 30
days

Anti-depressants: Fluoxetine (e.g., Prozac); Sertraline (e.g.,
Zoloft); Escitalopram (e.g., Lexapro); Citalopram (e.g., Celexa);
Amitriptyline (e.g., Elavil); Trazadone (e.g., Desyrel);
Duloxetine (e.g., Cymbalta) or other anti-depressants

37. You have answered “yes” to having taken anti-depressants in the past 30 days. Do you
have a prescription for this medication?
YES, I have a prescription for this medication
NO, I do not have a prescription for this medication

38. Stimulants
YES, I have taken
this in the past 30
days

NO, I have not
taken this in the
past 30 days

Stimulants: ADHD medications such as
Methylphenidate (e.g., Ritalin, Aderall,
Metadate, Concerta)

39. You have answered “yes” to having taken stimulants in the past 30 days. Do you have a
prescription for this medication?
YES, I have a prescription for this medication
NO, I do not have a prescription for this medication

40. Synthetic or Semi Synthetic Opioids *
YES, I have
taken this in the
past 30 days

NO, I have not
taken this in the
past 30 days

Synthetic Opioids (e.g., Methadone) or Semi
Synthetic Opioids (e.g., Buprenorphine,
Suboxone, Subutex) *

41. You have answered “yes” to having taken synthetic or semi synthetic opioids in the past 30
days. Do you have a prescription for this medication?
YES, I have a prescription for this medication
NO, I do not have a prescription for this medication

OVER-THE COUNTER MEDICATIONS
Page description:
You have answered “yes” to having used over-the-counter medications in the past 30 days.
Remember this survey is completely anonymous. The information you provide will not be
reported to anyone and will only be used for research purposes.

42. Did you read the label and information found on bottle or in the package that discusses the
possibility that these medications could have an effect on your ability to drive safely?
YES
NO

43. Do you believe that using any of these medications can affect your ability to drive safely?
YES
NO

44. Have you ever driven while using any of these medications in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when using these medications.

45. In the past year, has using any of these medications ever affected your ability to drive
safely?
YES
NO

MARIJUANA/HASHISH
Page description:
You answered “yes” to having used marijuana or hashish in the past 30 days. This is also
called “pot,” “weed,” “hash,” or other names. (This refers to smoking marijuana/hashish or,
eating or drinking products containing marijuana/hashish (consuming marijuana-infused food
products, also known as “edibles”). Remember this survey is completely anonymous. The
information you provide will not be reported to anyone and will only be used for research
purposes.

46. In the past 30 days, have you used marijuana/hashish for pain relief or to ease symptoms of
a medical issue such as cancer treatment or other medical problems, even if “medical
marijuana” is not legal in your state or jurisdiction?
YES
NO

47. In the past 30 days, have you obtained a medical marijuana permit or other state-approved
medical marijuana card that allows you to purchase and use “medical marijuana”? (NOTE: Not
all states or jurisdictions allow “medical marijuana.”)
YES
NO

48. Did a medical professional (e.g., doctor, nurse practitioner, or physician’s assistant), who
may have recommended you receive a medical marijuana permit, discuss the possible affect
marijuana/hashish could have on your driving?
YES
NO

49. Do you believe that using marijuana/hashish for either recreational or medical reasons can
affect your ability to drive safely?
YES
NO

50. Have you ever driven while using marijuana in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when using marijuana.

51. In the past year, has using marijuana/hashish ever affected your ability to drive safely?
YES
NO

K-2/SPICE/Herbal Incense/Synthetic Marijuana
Page description:
You answered “yes” to having used Spice/K2/Herbal Incense in the past 30 days. (NOTE:
"Spice" or “K2” refers to a wide variety of herbal/spice/plant mixtures that are sprayed with a
chemically similar to marijuana. Sometimes it is referred to as “synthetic cannabis” or “synthetic
marijuana.”) Remember this survey is completely anonymous. The information you provide will
not be reported to anyone and will only be used for research purposes.

52. Do you believe using synthetic marijuana could affect your ability to drive safely?
YES
NO

53. Have you ever driven while using synthetic marijuana in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when using synthetic marijuana.

54. In the past year, has using marijuana ever affected your ability to drive safely?
YES
NO

BATH SALTS (SYNTHETIC CATHINONES)
Page description:
You answered “yes” to having used bath salts in the past 30 days. (NOTE: These are not salts
that you put in a bath. These are drugs containing chemicals related to cathinones, an
amphetamine-like stimulant that may be sold legally in some states or jurisdictions, but are
used to make you “high.”) Remember this survey is completely anonymous. The information
you provide will not be reported to anyone and will only be used for research purposes.

55. Do you believe using bath salts (synthetic cathinones) could affect your ability to drive
safely?
YES
NO

56. Have you ever driven while using bath salts (synthetic cathinones) in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when using bath salts.

57. In the past year, has using bath salts (synthetic cathinones) ever affected your ability to drive
safely?
YES
NO

INHALANTS
Page description:
You answered “yes” to having used inhalants in the past 30 days. (NOTE: This includes the use
of legally available substances such as glue, correction fluid, nitrous oxide, or ‘whippits’ that are
used to make you “high.”) Remember this survey is completely anonymous. The information
you provide will not be reported to anyone and will only be used for research purposes.

58. Do you believe using the inhalants could affect your ability to drive safely?
YES
NO

59. Have you ever driven while using inhalants in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when using inhalants.

60. In the past year, has using inhalants ever affected your ability to drive safely?
YES
NO

COCAINE/CRACK
Page description:
You answered “yes” to having used cocaine or crack (e.g., inhaled, injected, or freebased) in
the past 30 days. Remember this survey is completely anonymous. The information you provide
will not be reported to anyone and will only be used for research purposes

61. Do you believe using cocaine or crack could affect your ability to drive safely?
YES
NO

62. Have you ever driven while using cocaine/crack in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when using cocaine/crack.

63. In the past year, has using cocaine/crack ever affected your ability to drive safely?
YES
NO

AMPHETAMINES
Page description:
You answered “yes” to having used amphetamines in the past 30 days. (NOTE: This includes
Meth, Ecstasy, or MDMA, also known as Molly/Mandy). Remember this survey is completely
anonymous. The information you provide will not be reported to anyone and will only be used
for research purposes.

64. Do you believe using amphetamines could affect your ability to drive safely?
YES
NO

65. Have you ever driven while using amphetamines in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when using amphetamines.

66. In the past year, has using amphetamines ever affected your ability to drive safely?
YES
NO

HEROIN
Page description:
You answered “yes” to having used heroin in the past 30 days (e.g., inhaled, smoked, or
injected). Remember this survey is completely anonymous. The information you provide will not
be reported to anyone and will only be used for research purposes.

67. Do you believe using heroin could affect your ability to drive safely?
YES
NO

68. Have you ever driven while using heroin in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when using heroin.

69. In the past year, has using heroin ever affected ability to drive safely?
YES
NO

PCP
Page description:
You answered “yes” to having used PCP (also known as Angel Dust) in the past 30 days.
Remember this survey is completely anonymous. The information you provide will not be
reported to anyone and will only be used for research purposes.

70. Do you believe using PCP could affect your ability to drive safely?
YES
NO

71. Have you ever driven while using PCP in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when using PCP.

72. In the past year, has using PCP ever affected your ability to drive safely?
YES
NO

HALLUCINOGENS
Page description:
You answered “yes” to having used hallucinogens in the past 30 days. (NOTE: These are drugs
such as Acid/LSD, Mushrooms, Ketamine/“Special K.”) Remember this survey is completely
anonymous. The information you provide will not be reported to anyone and will only be used
for research purposes.

73. Do you believe using hallucinogens could affect your ability to drive safely?
YES
NO

74. Have you ever driven while using hallucinogens in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when using hallucinogens.

75. In the past year, has using hallucinogens ever affected your ability to drive safely?
YES
NO

OTHER DRUGS NOT INCLUDED IN THIS SURVEY
Page description:
You answered “yes” to having used other drugs in the past 30 days that are not included in this
survey. Remember this survey is completely anonymous. The information you provide will not
be reported to anyone and will only be used for research purposes.

76. What other drugs have you used that were not included in this survey?

77. Do you believe using the drug(s) you named could affect your ability to drive safely?
YES
NO

78. Have you ever driven while using other drugs in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when using other drugs.

79. In the past year, has using other drugs ever affected your ability to drive safely?
YES
NO

PRESCRIPTION MEDICATIONS
Page description:
You answered “yes” to having taken prescription medications in the past 30 days. Remember
this survey is completely anonymous. The information you provide will not be reported to
anyone and will only be used for research purposes.

80. Did a medical professional (e.g., doctor, nurse practitioner, or physician’s assistant) discuss
the possible affect these prescription medications could have on your driving?
YES
NO

81. Do you believe taking any of these medications can affect your ability to drive safely?
YES
NO

82. Have you ever driven while taking any of these medications in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when taking these medications.

83. In the past year, has taking any of these medications ever affected your ability to drive
safely?
YES
NO

COMBINING SUBSTANCES
Page description:
This section of the survey asks about combining medications/drugs, either with alcohol or with
other medications/drugs. Remember this survey is completely anonymous. The information you
provide will not be reported to anyone and will only be used for research purposes.

84. In the past 30 days, did you ever combine drinking alcohol with taking any medications or
drugs? This includes prescription medications (e.g., prescribed or not prescribed), over-thecounter medications, marijuana, or any other drugs.
YES
NO

85. You answered “yes” to the previous question about combining alcohol with medications or
drugs. Please indicate which type of medications or drug(s) you used while drinking alcohol
(check all that apply):
Alcohol and prescription medications/drugs (i.e., legally prescribed for you)
Alcohol and prescription medications/drugs (i.e., not legally prescribed to you)
Alcohol and over-the-counter medications (e.g., cold or cough medication)
Alcohol and marijuana/hashish
Alcohol and other drugs (e.g., bath salts, cocaine, heroin, amphetamines, PCP, etc.)

86. Did a medical professional (e.g., doctor, nurse practitioner, or physician’s assistant) ever
discuss the possibility that combing alcohol with any of these medications or drugs might affect
your ability to drive safely?
YES
NO

87. Do you believe drinking alcohol and taking other medications/drugs can affect your ability to
drive safely?
YES
NO

88. Have you ever driven while drinking alcohol and taking other medications/drugs in the past
year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when drinking alcohol and taking other medications/drugs.

89. In the past year, has drinking alcohol and taking other medications/drugs ever affected your
ability to drive safely?
YES
NO

COMBINING DRUGS
Page description:
You answered “yes” to having taken two or more of the drugs discussed in this survey in the
past 30 days. Remember this survey is completely anonymous. The information you provide
will not be reported to anyone and will only be used for research purposes.

90. In the past 30 days, have you taken two or more of the medications/drugs discussed in this
survey at the same time (or within a few hours)?
YES
NO

91. You answered “yes” to the previous question about combining two different
medications/drugs within a few hours. Please indicate which type of medications/drug you
combined (check as many as apply):
I combined two or more prescription medications.
I combined marijuana/hashish with a prescription medication.
I combined prescription medications/drugs with another drug.
I combined two or more drugs.
I combined over-the-counter medications with another drug.

92. Did a medical professional (e.g., doctor, nurse practitioner, or physician’s assistant) ever
discuss the possible affect that combining drugs could have on your driving?
YES
NO

93. Do you believe combining two or more of these drugs can affect your ability to drive safely?
YES
NO

94. Have you ever driven while combining two or more of these drugs in the past year?
YES
YES, but I waited until I thought it was safe to drive.
NO
NO, I avoid driving when combining two or more of these drugs.

95. In the past year, has combining two or more of these drugs ever affected your ability to drive
safely?
YES
NO

ADDITIONAL INFORMATION
Page description:

96.
You answered “yes” to a previous question about driving after having used medications, drugs,
or alcohol during the past 30 days. Remember this survey is completely anonymous. The
information you provide will not be reported to anyone and will only be used for research
purposes. What was the reason for driving following the use of medications/drugs and/or
alcohol (please check all that apply)?
Work
Family responsibilities
Household responsibilities (e.g., going to the grocery store, pharmacy, or other stores)
Restaurant/leisure/recreation/entertainment
Needed to get home
I did not think it would be a problem
Other

97. We’d like to know what you think about driving and the use of alcohol, drugs, or
medications. Please check which substances you believe might increase your chances of
getting hurt while driving, even if you do not use any of these substances. Please check all
substances you feel might affect your ability to drive safely: *
Alcohol
Over-the-counter medications
Marijuana/hashish
Illegal drugs such as cocaine, heroin, PCP, meth, bath salts, inhalants, etc.
Prescription medications/drugs from the previous lists (e.g., those prescribed to you
and/or those used without a prescription)
Combining alcohol with the medications/drugs discussed in this survey
Combining two or more medications/drugs discussed in this survey

Thank You!

THANK YOU FOR ANSWERING OUR QUESTIONS!
If you want to know more about how medications and drugs can affect your driving please
check out our website: www.drugdrivinginfo.com or www.stayinlane.com Thank you for
completing our survey! Please visit the National Gift Card website http://www.ngcgroup. com/
and enter the code XXXX. You will then be able to select a gift card from among 70 or so online
retailers or brick and mortar stores/restaurants. If you have any questions or concerns about
obtaining a gift card, please call us at 800-XXX-XXXX, or contact us at
[email protected].