NHTSA Form 1338 Demographics Questionnaire

OMB#: 2127-xxxx

Expiration Date: xx/xx/xxxx

Virginia Tech Transportation Institute

HV-CWI Questionnaire - Demographics

This collection of information is voluntary and will be used to screen for eligible participants. Public reporting burden is estimated to average 2 minutes per person, including the time for reviewing instructions searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Information will be kept confidential, and your name will not be attached to any data. Please note that 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. The OMB control number for this collection is 2127-XXXX. 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, National Highway Traffic Safety Administration, 1200 New Jersey Avenue, SE, Washington, DC 20590.

General Information:

Date:
Gender:
Age:
CDL Expiration:
State of Issuance:
Medical Card Expiration:

Driving History:

1. How many years have you been a commercial motor vehicle operator?

__________

2. Are you a million mile driver? YES or NO

3. How many at-fault accidents have you had while driving a commercial motor vehicle? _________

4. Please circle any of the endorsements that are currently valid on your CDL:

Doubles/Triples

Tanker

Hazardous

Passenger

School Bus

5. Please describe the following:

1. Hours driven per week: ___________________________

2. Miles driven per week: ___________________________

6. Please classify your current or most recent employment driving a commercial motor vehicle:

1. Vehicle type:

   1. Class 8 truck with trailer

   2. Motorcoach bus

   3. Transit bus

   4. School bus

2. Distance:

   1. Long-haul/national (over 500 miles per trip)

   2. Short-haul/regional (between 50 and 499 miles per trip)

   3. Local/delivery (less than 50 miles per trip)

3. Type of operation (select one):

   1. For Hire Truckload

(Company hired to haul other company’s goods, e.g. Schneider)

2. For Hire Less-Than-Truckload (LTL)

(Company hired to haul other company’s goods that are generally 10,000lbs or less, e.g. Old Dominion)

3. Private fleet

(Company that hauls own goods, e.g. Wal-Mart)

4. Line-haul

(Travels from terminal to terminal, no pick-up/delivery, e.g. Pitt Ohio)

5. Passenger transport

7. Have you ever been employed at a trucking or bus company in a position other than driver?

YES or NO

If yes, please describe:______________________________________________

NHTSA Form 1338