Form NHTSA Form 1426 NHTSA Form 1426 Demographic Questionnaire

OMB Control No. 2127-XXXX

Expiration Date xx/xx/xxxx

Participant ID________________

This collection of information is voluntary and will be used for formative purposes only so that we may develop vehicle safety programs designed to reduce the number of traffic-related injuries and deaths. 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 2127-XXXX. Public reporting for this collection of information is estimated to be approximately six minutes per response, including the time for reviewing instructions, 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, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590

Demographics

1. What is your gender? _______________

2. What is your age? _______________

3. Do you wear corrective lenses while driving? _______________

4. Do you wear a hearing aid while driving? _______________

5. How long have you had a CDL? _____ years _____ months

6. How many years have you driven truck tractors? _______________

7. What type of loads or trailers do you typically pull (Circle any that apply)?

Box trailer Tanker trailer Flatbed trailer Specialty loads

Other (Please explain): _____________________________________________

8. How long have you driven for your current company? _______________

9. How long have you driven your current truck? _____ years _____ months

10. How would you describe your current route? (Please circle one below)

Over the road Dedicated route Local route

Other (Please explain): _____________________________________________

11. In what region does the majority of your driving occur? (Please circle one below)

Northeast Southeast Midwest Southwest West

Other (Please explain): _____________________________________________

12. How long have you driven your current route? _____ years _____ months

13. Do you train drivers for your company? ___ Yes ___ No

14. About how many miles have you driven on duty in the last year? _______________

15. How many hours are you typically on-duty per week? _______________

16. How many hours are you typically driving per week? _______________

17. Have you ever used collision avoidance systems before? ___ Yes ___ No

    1. If yes, how long have you used them? _____ years _____ months

    2. If yes, which devices has you used (i.e. VORAD, Wingman^®, OnGuard^TM)? _________________________________________________________________

18. Did you receive training for your current collision avoidance system? ___ Yes ___ No

    1. If yes, please indicate which types of training you received (check any that apply):,

___ In-vehicle Demonstration ___ Instructional Video

___ Classroom Instruction ___ Instruction from Safety Manager

___ Brochure / Manual ___ Instruction from Other Drivers

___ Other (Please describe): ________________________________________

19. Has the collision avoidance system on your truck ever been serviced or recalibrated?

___ Yes ___ No

If yes, please describe: ____________________________________________________

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NHTSA Form 1426