Background Questionnaire

Attachment

J

Form Approved

OMB No. XXXX-XXXX

Exp. Date XX/XX/XXXX

Background Questionnaire (only given at enrollment)

Information on this form will be kept confidential within the research team
and will not be shared with your company.

Please answer all questions as accurately as possible.

Date

Site

1. DEMOGRAPHIC AND EMPLOYMENT

1. What is your age? _________ years

2. Gender: ☐ Male ☐ Female

3. Years of commercial truck driving experience ____________ years

4. How long have you worked at your present company? _______years _______months

5. Type of driver: ☐ Day ☐ Night ☐ Mixed

6. What type of CDL endorsement/restrictions do you have? (Check all that apply.)

☐ Air brakes restriction (L) ☐ Intrastate only (K)

☐ Passenger (P) ☐ Double/triple trailer (T)

☐ Tank (N) ☐ HazMat (H)

☐ Tank and HazMat (X) ☐ Other, please specify _____________________

2. WORK CONDITIONS

7. We’d like to know how many miles you drove your truck in the last 12 months, excluding any miles driven by others. Estimate how many miles you were actually behind the wheel in the last 12 months.

MILES |___|___|___|___|___|___|

7. Considering your work schedule, how many days did you have the opportunity to sleep at home in the last 30 days?

Number of days |___|___|

Public reporting burden of this collection of information is estimated to average 45 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).

7. Where do you usually take your longest sleep period on days that you drive your truck and away from home? Is it…

In a motel, 1

In the truck, or 2

Somewhere else? 91

(SPECIFY)

7. On average, how many hours (including naps and primary sleep) did you sleep each day in the past 7 days.

Hours |___|

11. Have you received training in a classroom setting for any of the following topics in the last 12 months?

	YES	NO
a. Federal regulations concerning trucking safety, such as the Hours of Service regulation?	1	2
b. Safe driving practices and/or defensive driving?	1	2
c. Fatigue and fatigue management?	1	2
d. Health and wellness?	1	2

3. HEALTH CONDITIONS

12. Do you (circle all the apply): smoke cigarettes, smoke cigars; chew tobacco, e-cigarette/vape

    1. If you circled any of the responses in #13, how much do you smoke on a typical day (1 large cigar or 200 vape puffs = 1 pack of cigarettes; 1 can of dip = 4 packs of cigarettes)

☐ less than ½ pack day ☐ ½ to 1 pack/day ☐ more than 1 pack/day

12. Regarding your vision, which of the following applies:

☐Contact Lenses ☐ Glasses to drive ☐Reading Glasses ☐Corrective eye surgery ☐ No Contact Lenses and No Glasses

12. Have you ever been told by a doctor or other health professional that you have any of the following conditions? (Check all that apply to you.)

☐ Diabetes ☐ High Blood Pressure ☐ Heart Disease ☐ Insomnia ☐ Heart Burn ☐ Asthma

12. Are you currently taking medicine for? (Check all that apply to you)

☐ Diabetes ☐ Heart disease ☐ High blood pressure ☐ Insomnia

☐ Breathing, including inhalers

12. How often do you experience body pain (excluding a recent injury, such as closing door on hand or stubbing toe) of any kind during a typical daily work shift? (Check only 1 box)

☐ 0–5% of shift ☐ 6–25% of shift ☐ 26–50% of shift ☐ 51–75% of shift

☐ 76% or more of shift

12. How tall are you? ______ feet _____ inches

13. What is your weight? ____________ pounds (lbs)

14. What is your neck size? ____inches

15. Have you ever undergone a heart operation procedure? ☐ Yes ☐ No

16. Do you take medication to thin your blood? ☐ Yes ☐ No

17. Do you have COPD (emphysema)? ☐ Yes ☐ No

18. Have you been treated for depression? ☐ Yes ☐ No

19. Do you take medicines to control your blood sugar? ☐ Yes ☐ No

20. Do you take medications for your heart? ☐ Yes ☐ No

21. Do you snore louder than talking? ☐ Yes ☐ No

22. Does your snoring bother other people? ☐ Yes ☐ No

23. Do you take any of the following medications (Protonix, Prevacid, Nexium, Pepcid, or Tagamet)? ☐ Yes ☐ No

24. On average, do you urinate more than once per sleep period? ☐ Yes ☐ No

25. Do you become drowsy while driving? ☐ Never ☐ Sometimes ☐ Often

26. Does head back, neck, or joint pain affect your sleeping? ☐ Yes ☐ No

27. Do you take any medications to control your blood pressure, including diuretics (fluid pills)?

☐ Yes ☐ No

12. Do you sleep restlessly or find the blankets on the floor in the morning? ☐ Yes ☐ No

13. Has anyone ever noticed that you quit breathing during your sleep? ☐ Yes ☐ No

14. Have you awakened from sleep with gasping breaths? ☐ Yes ☐ No

15. Do you take estrogen replacement therapy? ☐ Yes ☐ No

4. SLEEP APNEA

37. My doctor and I have talked about obstructive sleep apnea

    1. Yes (skip the next question)

    2. No (please answer question 38)

    3. Don’t know (skip to question 43)

    4. Refused (skip to question 43)

38. If you and your doctor have not talked about sleep apnea, is it because

    1. I do not know what sleep apnea is

    2. My doctor and/or I do not believe that I have sleep apnea

    3. I am afraid of losing my job

    4. Don’t know

    5. Refused

39. Have you ever been told by a doctor or other health professional that you have obstructive sleep apnea?

    1. Yes

    2. No

    3. Don’t know

    4. Refused

40. I currently use the following for my sleep apnea (pick one)

[Only ask this question if the respondent says that a doctor told them they have sleep apnea]

1. CPAP (Skip to question 43)

2. APAP (Skip to question 43)

3. BiPAP (Skip to question 43)

4. Other—Please specify:_________________________________ (Skip to question 43)

5. Not currently on treatment for sleep apnea

37. If you aren’t treating your sleep apnea, do you plan to start treating it within the next 2 months? [Only ask this question if the respondent answered “Not currently on treatment for sleep apnea” for question 40]

    1. Yes

    2. No

    3. Maybe

    4. Don’t know

38. If you aren’t treating your sleep apnea, what are the main reasons? (Check all that apply)

[Only ask this question if the respondent says that a doctor told them they have sleep apnea]

1. Discomfort of treatment

2. Expense of treatment

3. Inconvenient to use

4. Just haven’t gotten around to it yet

5. Don’t want to go to the doctor

6. Treatment isn’t that effective for me

7. My sleep apnea is not that bad

8. Other—Please specify__________

9. Don’t know

5. FATIGUE

43. My company has written policies about obstructive sleep apnea management.

1. Yes

2. No

3. Don’t know

44. How much of a problem is fatigue to you personally in your job (Mark one response)?

    1. A major problem

    2. A minor problem

    3. Not a problem at all

45. How much of a problem is fatigue to drivers in your company (Mark one response)?

    1. A major problem

    2. A minor problem

    3. Not a problem at all

46. What main difficulties do you have in avoiding driving while drowsy? (Mark any that apply to you).

    1. Driving schedule is too tight to take breaks

    2. Lack of good places to stop to take a break when I need it

    3. Not enough hours to sleep during my main sleep time

    4. Difficulty sleeping well at home or motel

    5. Difficulty sleeping well in sleeping berth in the truck

    6. Never have had the difficulty of driving while drowsy

    7. Other—Please specify:________________________

47. How well do you think drivers in your organization do in keeping drowsiness while driving to a minimum?

    1. Extremely badly

    2. Quite badly

    3. Quite well

    4. Extremely well

    5. Don't have an opinion

48. How well do you think you do personally at keeping drowsiness while driving to a minimum?

    1. Extremely badly

    2. Quite badly

    3. Quite well

    4. Extremely well

    5. Don't have an opinion

49. Indicate your belief with each of the following statements on a 5-point scale:

    1. Driving while drowsy is:

☐ Not dangerous ☐ Slightly Dangerous ☐ Dangerous ☐ Moderately Dangerous

☐ Extremely dangerous

2. For me, avoiding driving while drowsy is

☐ Extremely Difficult ☐ Difficult ☐ Neutral ☐ Easy ☐ Extremely Easy

3. For me, getting sufficient and proper sleep is:

☐ Extremely Difficult ☐ Difficult ☐ Neutral ☐ Easy ☐ Extremely Easy

4. For me, to stop driving when I get drowsy and take a nap is:

☐ Extremely Difficult ☐ Difficult ☐ Neutral ☐ Easy ☐ Extremely Easy

5. Drivers in my company would expect me to avoid driving while drowsy.

☐ Disagree ☐ Slightly Disagree ☐ Neutral ☐ Slightly Agree ☐ Agree

6. Management in my company would expect me to avoid driving while drowsy.

☐ Disagree ☐ Slightly Disagree ☐ Neutral ☐ Slightly Agree ☐ Agree

7. I try to reduce my drowsiness on the road by getting plenty of sleep each day.

☐ Disagree ☐ Slightly Disagree ☐ Neutral ☐ Slightly Agree ☐ Agree

8. I will reduce my drowsiness on the road by increasing the amount of sleep I get each day.

☐ Disagree ☐ Slightly Disagree ☐ Neutral ☐ Slightly Agree ☐ Agree

9. I usually continue to drive when I feel drowsy, and fight to stay alert.

☐ Disagree ☐ Slightly Disagree ☐ Neutral ☐ Slightly Agree ☐ Agree

10. I intend more often in the future to stop driving when I feel drowsy, and take a break or a nap.

☐ Disagree ☐ Slightly Disagree ☐ Neutral ☐ Slightly Agree ☐ Agree

44. How likely are you to doze off or fall asleep during each activity? Use a scale from 0 to 3, with 0 being “I would never doze or fall asleep,” and34 being “that it would be highly likely that you would doze off or fall asleep.” Even if you have not done some of these things in the past week, try to think how they would have affected you...

	WOULD NEVER DOZE	SLIGHT CHANCE	MODERATE CHANCE	HIGH CHANCE
a. Sitting and reading?	0	1	2	3
b. Watching TV?	0	1	2	3
c. Sitting inactive in a public place such as a theatre or meeting?	0	1	2	3
d. As a passenger in a vehicle for an hour without a break?	0	1	2	3
e. Lying down in the afternoon when circumstances permit?	0	1	2	3
f. Sitting and talking to someone?	0	1	2	3
g. Sitting quiet after a lunch	0	1	2	3
h. In a vehicle, while stopped for a few minutes in traffic?	0	1	2	3

End of the survey. Thank you!