1448 Drive Break Survey

Study: _____________________

Participant: _______________

Date: ______________________

Break Start Time: _________ OMB Control Number: 2127-NEW

Break End Time: ___________ Expiration Date: MM/DD/YYYY

Break Start Survey

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 2127-NEW (expiration date: MM/DD/YYYY). The average amount of time to complete the screening is five 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) Please describe why you chose to stop:

_____________________________________________________________________________________

_____________________________________________________________________________________

2) Stanford Sleepiness Scale (please circle one)

Degree of Sleepiness	Scale Rating
Feeling active, vital, alert, or wide awake	1
Functioning at high levels, but not at peak; able to concentrate	2
Awake, but relaxed; responsive but not fully alert	3
Somewhat foggy, let down	4
Foggy; losing interest in remaining awake; slowed down	5
Sleepy, woozy, fighting sleep; prefer to lie down	6
No longer fighting sleep, sleep onset soon; having dream-like thoughts	7
Asleep	X

Break End Survey

3) Stanford Sleepiness Scale (please circle one)

Degree of Sleepiness	Scale Rating
Feeling active, vital, alert, or wide awake	1
Functioning at high levels, but not at peak; able to concentrate	2
Awake, but relaxed; responsive but not fully alert	3
Somewhat foggy, let down	4
Foggy; losing interest in remaining awake; slowed down	5
Sleepy, woozy, fighting sleep; prefer to lie down	6
No longer fighting sleep, sleep onset soon; having dream-like thoughts	7
Asleep	X

2

NHTSA Form 1448