Form Driver Form 2 Driver Form 2 Background Questionnaire

Flexible Sleeper Berth Pilot Program

Sleeper Berth Pilot Program Background Questionnaire

Participanting Driver Tasks - Background questionnaire

OMB: 2126-0066

Document [docx]
Download: docx | pdf

OMB NO: XXXX-XXXX
EXPIRATION DATE:
mm/dd/yyyy

Participant ID: _________

Public Burden Statement


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 XXXX-XXXX. Public reporting for this collection of information is estimated to be approximately 5 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. 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.



Flexible Sleeper Berth – Background Questionnaire

Information on this form will be kept confidential within the research team
and will not be shared with your company.

Please answer all questions as accurately as possible.



  1. What is your age? _________ years

  2. Gender: Male Female

  3. How tall are you? ______ feet _____ inches

  4. What is your weight? ____________ pounds (lbs)

  5. Years of commercial driving experience ____________ years

  6. Do you have a million miler safety record? Yes No

    1. If yes: 1 million miles 2 million miles 3 million miles

  7. Have you taken any modules from the North America Fatigue Management Program? Yes No

    1. If yes, check all that apply:

Module 1: FMP Introduction and Overview

Module 2: Safety Culture and management Practices

Module 3: Driver Education

Module 4: Driver Family Education

Module 5: Train-the-Trainer for Driver Education and Family Forum

Module 6: Shippers and Receivers

Module 7: Motor Carrier Sleep Disorders Management

Module 8: Driver Sleep Disorders Management

Module 9: Driver Scheduling and Tools

Module 10: Fatigue Monitoring and Management Technologies

  1. How long have you worked at your present company? _______years _______months

  2. Type of driver: Day Night Mixed

  3. What is your home terminal time zone used for HOS logs?

Eastern Central Mountain Pacific

  1. What is your driving type?

Local Regional Over-The-Road

  1. What is your operational type?

Intermodal Dedicated

Flatbed Temperature control

Van truckload Other, please specify _____________________

  1. What type of CDL endorsement/restrictions do you have? (Check all that apply.)

Air brakes restriction (L) Intrastate only (K)

Passenger (P) Double/triple trailer (T)

Tank (N) HazMat (H)

Tank and HazMat (X) Other, please specify _____________________

  1. What type of trailer do you typically use?

Dry Van (Box Trailer) Flatbed Trailer Tank Trailer (Tanker)

Refrigerated Trailer Specialized Trailer

  1. Is your truck equipped with any of the following? (Check all that apply.)

Auxiliary Power Unit Espar Heater

Optimized Idle Other Idle Reduction Technology: ______________________



  1. Do you ever use platooning? Yes No

  2. Do you wear contact lenses? Yes No

  3. Do you wear glasses when driving? Yes     No

  4. Has a physician informed you that you have any of the following conditions? (Mark all that apply to you.)

Sleep apnea Diabetes

High blood pressure Insomnia

  1. Do you use any of the following? (Mark all that apply to you)

CPAP for sleep apnea Medication for diabetes

Medication for high blood pressure Medication for insomnia

  1. How often do you experience pain of any kind during a typical daily work shift? (Check only 1 box)

0–5% of shift 5–25% of shift 25–50% of shift 50–75% of shift 75% or more of shift

  1. Do you typically consume caffeine?

No Yes (If yes, for all categories that apply, indicate amount consumed in a typical day.)

Coffees _______ cups per day Cola drinks _______ drinks per day

Energy drinks _______ drinks per day Caffeine pills _______ pills per day

Caffeine gum _______ sticks/pieces per day Tea (not herbal) _______ cups per day

  1. Do you typically use tobacco or nicotine products?

No Yes (If yes, for all categories that apply, indicate amount used in a typical day.)

Cigarettes _______ cigarettes per day Cigars _______ cigars per day

Chew tobacco _______ pinches/pouches per day Smoke pipe _______ bowls per day

Nicotine gum _______ sticks/pieces per day E-cigarettes _______ mL per day (w/nicotine)
_______mg nicotine per mL



Thank you!

Page 1 of 3

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleDRIVER INFORMATION FORM
AuthorHonn, Kimberly
File Modified0000-00-00
File Created2021-01-21

© 2024 OMB.report | Privacy Policy