Form 1422 Control Driver Questionnaire

OMB Control Number: XXXX-XXX

Expiration Date: XX/XX/XXXX

Control Driver Questionnaire

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to 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 (expiration date: MM/DD/YYYY). The average amount of time to complete the questionnaire is 5 minutes. All responses to this collection of information are voluntary. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden send them to Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

1. What is your sex?

• Male

• Female

2. What is your age? __________ Years

3. What is your marital status?

• Single

• Living together

• Married

• Separated

• Divorced

• Widowed
  
  

4. Are you of Hispanic, Latino, or Spanish origin?

• No, not of Hispanic, Latino, or Spanish origin

• Yes, Mexican, Mexican Am., Chicano

• Yes, Puerto Rican

• Yes, Cuban

• Yes, another Hispanic, Latino, or Spanish Origin – Enter origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on.

  • ________________________________________
    
    

5. What is your race? (Select one or more options).

• White

• Black or African American

• American Indian or Alaska Native – Enter name of enrolled or principal tribe.

  • ________________________________________

• Asian Indian

• Chinese

• Filipino

• Japanese

• Korean

• Vietnamese

• Other Asian – Enter race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.

  • _______________________________________

• Native Hawaiian

• Guamanian or Chamorro

• Samoan

• Other Pacific Islander – Enter race, for example, Fijian, Tongan, and so on.

  • _______________________________________

• Some other race – Enter race.

• _______________________________________
  
  

6. What is the highest degree or level of school you have completed?

• None - 8th grade

• 9th - 11th grade

• High school graduate

• Some college, no degree

• Associate’s degree (for example: AA, AS)

• Bachelor’s degree (for example: BA, BS)

• Master’s degree (for example: MA, MS, MEng, Med, MSW, MBA)

• Professional degree (for example: MD, DDS, DVM, LLB, JD)

• Doctorate degree (for example: PhD, EdD)

7. How tall are you without shoes? ____feet ____ inches or ____ meters _____centimeters

8. How much do you weigh without clothes or shoes? ____ pounds or ____ kilograms

9. A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition. About how long has it been since you last visited a doctor for a routine checkup?

• Within the past year (anytime less than 12 months ago)

• Within the past 2 years (1 year but less than 2 years ago)

• Within the past 5 years (2 years but less than 5 years ago)

• 5 or more years ago

• Don’t know/Not sure

• Never

10. Where are you coming from?

• Own home

• Someone else's home

• Work

• Restaurant / Eating place

• Bar / Tavern / Club

• Sport or Rec facility / Park

• School / Church

• Store / Gas station

• Hotel / Motel

• Beach

• Military Base

• Other
  
  

11. Where are you headed?

• Own home

• Someone else's home

• Work

• Restaurant / Eating place

• Bar / Tavern / Club

• Sport or Rec facility / Park

• School / Church

• Store / Gas station

• Hotel / Motel

• Beach

• Military Base

• Other

12. Do you think a person can drive safely within 1 hour of using:

	Yes	No	Not sure
Blood pressure medication
Over-the-counter pain relievers (e.g., Tylenol, Advil, Aleve)
Prescription opioid pain relievers (e.g., hydrocodone, oxycodone, codeine)
Alcohol
Marijuana
Depression/anxiety drugs (e.g., Valium, Zoloft)

NHTSA Form 1422