Family Interactions

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Family Interactions

A “partner” can be anyone who would have enough information and interaction to answer the following questions. Some examples are: wife, husband, common-law partner, girlfriend, boyfriend, son, daughter, roommate, mother, father, etc.

Due to the variety of relationships mentioned above, not all questions will apply. If a question does not apply or if you do not wish to answer then skip the question.

1. Please rate your partner’s knowledge about the underlying effects of fatigue on your job as a truck driver?

☐Low ☐Medium ☐High

2. Rate the level of fatigue you see typically experience around your partner?

☐Low ☐Medium ☐High

3. Have you ever found family life to be difficult as a result of your job as a truck driver?

Yes  No 

If yes, please describe these difficult times and why you felt that they were difficult (i.e., beginning of relationship, childcare problems, etc.):________________________________

_________________________________________________________________________

_________________________________________________________________________

1. How has fatigue affected your partner’s life in the following areas:

a. Love life/sexual relationship A lot Moderate Some  Not at All

b. Interaction with children A lot Moderate Some  Not at All

c. Day to day chores A lot Moderate Some  Not at All

d. Social activities A lot Moderate Some  Not at All

e. Interaction as a family or with other family member A lot Moderate Some  Not at All

Public reporting burden of this collection of information is estimated to average 15 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)

5. How effectively does your partner deal with your fatigue?

Very Effectively Neutral Not Effectively

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