Attachment P - Driver Information

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 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 – Driver Information

Driver Type (circle): Large Carrier / Medium Carrier / Small Carrier / Owner Operator / Team Driver

Company: ________________________________________________________________________________

Study session begin date: _____/_____/_____ Latest possible end date: _____/_____/_____

Study Smartphone Number: _________

Actigraph Number: _________

OBMS Serial Number: _________ Install Date: _____/_____/_____

Pro400 ELD Serial Number: _________ Install Date: ___/___/___

ELD Tablet Number: _________

Truck Make: ___________ Model: ___________ License Plate: ___________

Briefing Session Date/Time (Study session begin date) _____/_____/_____ _____:_____

Informed Consent Signed? _________

Consented By ________________ Subject given copy of Informed Consent document? ____

Trained on Smartphone assessments? _____

Trained on Actigraph usage? _____

Trained on Orbcomm ELD? _____

Notes: ____________________________________________________________________________________

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