Attachment H - Driver Application

OMB NO: XXXX-XXXX

Expiration Date: mm/dd/yyyy

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 20 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 – Online Driver Application

Thank you for your interest in the Flexible Sleeper Berth Pilot Program. In order to determine your eligibility for the research study, please complete the following form. Your company must give permission for their drivers to participate. As such, we require information concerning your current company and team leader. We will review your application and contact you by phone or email to discuss your eligibility and potential study participation. Recruitment will be based on eligibility, company permission, geographic location, and meeting the study quotas for various driver types.

Name (first, middle initial, last): ___________________________________________________

Telephone (home, cell): __________________________________________________________

Preferred time of day to be called: __________________________________________________

Email address: _________________________________________________________________

Medical Examiner’s Certificate (MEC) expiration date: mm / dd / yyyy

Do you have a valid Commercial Driver’s License? ☐ Yes     ☐ No

Name of current company (or owner operator)? _______________________________________

Who is your supervisor? _________________________________________________________

What is your supervisor’s phone number? ____________________________________________

Do you typically operate: ☐ Solo ☐ In a team or couple ☐ Slip seat

Is your commercial vehicle: ☐ Company-owned ☐ Privately owned

Do you operate a vehicle with a GVWR of at least 10,001 lbs? ☐ Yes     ☐ No

DOT Number (on the door of your vehicle): __________________________________________

Where is your home terminal? _____________________________________________________

In what regions/states of the United States do you drive? ________________________________

Do you drive outside of the United States? ☐ Yes     ☐ No

Is your truck equipped with a sleeper berth?  ☐ Yes     ☐ No

If you marked ‘Yes’:

Does your sleeper berth meet the size, bedding, and other FMCSA requirements (found in 49 CFR part 393.76—Sleeper berths)? ☐ Yes     ☐ No

Do you regularly use your sleeper berth under the HOS sleeper berth provision (found in 49 CRF part 395—Hours of Service of Drivers)? ☐ Yes     ☐ No

Truck type: ☐ Single sleeper berth     ☐ Double sleeper berth

How do you currently log your duty and driving hours?

☐ Paper log     ☐ Electronic log     

If you marked ‘Electronic log’, which of the following systems do you use?

☐ Omnitracs ☐ PeopleNet

☐ Rand McNally ☐ JJ Keller

☐ BigRoad ☐ Other: ________________

Do you typically operate the same tractor each day? ☐ Yes     ☐ No

Please provide the following information concerning your tractor:

Make: ________________

Model: ________________

Year: ________________

VIN: ________________

Which of the following active safety systems are currently in place in your vehicle? Check all that apply [CM: Collision Mitigation; FCW: Forward Collision Warning; LDW: Lane Departure Warning]

☐ Meritor Wabco OnGuard (CM, FCW)

☐ Meritor Wabco OnLane (LDW)

☐ Mobileye C2-270 (FCW, LDW)

☐ Bendix Wingman ACB (FCW)

☐ Bendix Wingman Advanced (CM, FCW)

☐ Bendix Wingman Fusion (CM, FCW, LDW)

☐ Detroit Assurance (CM, FCW)

☐ Detroit Assurance (LDW)

☐ Other CM, specify: ________________

☐ Other FCW, specify: ________________

☐ Other LDW, specify: ________________

Thank you for your interest in the Flexible Sleeper Berth Pilot Program!

To complete your application, select ‘Submit’ below.

We will review your application and contact you by phone or email to discuss your eligibility and potential study participation.

Revised 8/13/2017 Page 1 of 3