Online Driver Application

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Online Driver Application

Thank you for your interest in the Evaluation of the North American Fatigue Management 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. 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)? _______________________________________

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

Public reporting burden of this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

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 regulation 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

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

Please provide the following information concerning your tractor:

Make: ________________

Model: ________________

Year: ________________

Thank you for your interest!

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.

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