Imp Driving - Attach 1 Qnne rev

Attachment 1: Questions to be cognitively tested

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Form Approved OMB #0920-0222; Expiration Date: 07/31/2018

Impaired Driving Proposed Questions for Cognitive Testing (2018 Module)

ALCDAY5: During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?

_____ Number of days per week

or

_____ Number of days per month

• None (GO TO 1B)

DRNKDRI2: During the past 30 days, how many times have you driven when you’ve had perhaps too much to drink?

_____ Number of times

• None (GO TO 1B)

1B: During the past 30 days, on how many days did you use marijuana?

_____ Number of Days

• None (GO TO PNPYN.A)

2B: During the past 30 days, in what way did you use marijuana the most? Please select ONE. Did you…

• Smoke it, for example, in a joint, bong, pipe, or blunt

• Eat it, for example, in brownies, cakes, cookies, or candy

• Drink it, for example, in tea, cola, or alcohol

• Vaporize it, for example, in an e-cigarette-like vaporizer or another vaporizing device

• Dab it, for example, using waxes or concentrates

• Use it some other way

3C: Do you have a recommendation or prescription from a healthcare provider to use marijuana?

• Yes (GO TO MARDRV1.B)

• No (GO TO 3C.1)

3C.1: When you used marijuana during the past 30 days, was it for medical reasons such as to treat or decrease symptoms of a health condition, or was it for non-medical reasons such as to get pleasure or satisfaction?

[INTERVIEWER NOTE: such as, excitement, to fit in with a group, increased awareness, to forget worries, for fun at a social gathering.]

• Only for medical reasons to treat or decrease symptoms of a health condition

• Only for non-medical purposes to get pleasure or satisfaction

• Both medical and non-medical reasons

MARDRV1.B: During the past 30 days, how many times have you driven within 2 hours of smoking or 4 hours of eating marijuana?

Number of times: _____

• None

MARDRVy.B: During the past 30 days, how many times have you driven while perhaps under the influence of alcohol AND marijuana?

Number of times: _____

• None

PNPYN.A: During the past 30 days, have you taken any prescription opioid pain medicine, either with or without a doctor’s prescription? Count drugs such as codeine, Vicoden, OxyContin, hydrocodone, and Percocet. Please do not include over-the-counter pain medicine such as aspirin, Tylenol, or Advil.

• Yes

• No (GO TO ILDUSE)

PNPDRV1.A: During the past 30 days, how many times have you driven on the same day after taking prescription opioid pain medicine, either with or without a doctor’s prescription?

Number of times: _____

• None

PNPDRV3.D: During the past 30 days, how many days have you driven while “high” or experiencing side effects (such as drowsiness, dizziness, or confusion) from a prescription opioid pain medicine?

Number of times: _____

• None

ILDUSE: During the past 30 days, have you used cocaine or methamphetamines?

• Yes

• No (GO TO CODE)

ILDDRV2.B: During the past 30 days, how many times have you driven while perhaps under the influence of cocaine or methamphetamines?

Number of times: _____

• None

CODE: In the past 30 days what substances, if any, did you use with other substances? [MARK ALL THAT APPLY]

• Alcohol alone, no other substances

• Marijuana alone, no other substances

• Prescription opioid pain medicine alone, no other substances

  • Cocaine or methamphetamines alone, no other substances

  • Other substance alone

  • Alcohol and marijuana at the same time

  • Alcohol and prescription opioid pain medicine at the same time

  • Alcohol and cocaine or methamphetamines at the same time

  • Alcohol, marijuana, and prescription opioid pain medicine at the same time

  • Alcohol, marijuana, and cocaine or methamphetamines at the same time

  • Alcohol, prescription opioid pain medicine and cocaine or methamphetamines at the same time

  • Other combination

  • None of the above, I didn’t use any substances (END INTERVIEW)

MARDRVy.C: In the past 30 days what substances, if any, were you under the influence of, while driving? [MARK ALL THAT APPLY]

• Alcohol alone, no other substances

• Marijuana alone, no other substances

• Prescription opioid pain medicine alone, no other substances

• Cocaine or methamphetamines alone, no other substances

• Other substance alone

• Alcohol and marijuana at the same time

• Alcohol and prescription opioid pain medicine at the same time

• Alcohol and cocaine or methamphetamines at the same time

• Alcohol, marijuana, and prescription opioid pain medicine at the same time

• Alcohol, marijuana, and cocaine or methamphetamines at the same time

• Alcohol, prescription opioid pain medicine and cocaine or methamphetamines at the same time

• Other combination

• None of the above, I didn’t drive under the influence of any substances

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