Form Pre-Study Demograp Pre-Study Demograp Attachment I - Pre-study Demographics

Pre-Study Demographic/Previous Experiences

Please respond to the following questions by either placing an “X” in the appropriate box or writing a clear answer in the space provided. There are no “correct” responses, please just be honest. All responses will only be used for research purposes and will not be used for regulatory purposes.

Demographics

1. What is your age? __________ (yrs)

2. What is your gender?

• Female

• Male

• Other

3. What is the highest academic degree you have earned (please check one)?

• Less than high school

• Some high school

• High school graduate or equivalence (for example, a GED)

• Some college, but degree not received or is in progress

• Associate’s Degree (for example a AA or AS)

• Bachelor’s Degree (for example a BA, BS, or AB)

• Master’s Degree

• Doctorate

• Professional degree (for example a MD, DDS, DVM, LLB, JD)

• None of the above

4. Is English your primary language (please check)? ___ Yes ___ No

If no, please indicate your primary language here _____________________

5. What is your height in feet _______(ft) and inches _______ (in)?

6. What is your weight in pounds __________ (lbs.)?

7. What is your race?

• American Indian or Alaska Native

• White

• Black or African American

• Asian

• Native Hawaiian or Other Pacific Islander

• Other ________________

Driving Experience

1. How long have you been driving commercial vehicles?

_____years _____ months

2. Are you currently employed as a commercial motor vehicle driver?

____ Yes ___ No

3. What class commercial driver’s license do you currently hold? _____________

4. Select the type of truck endorsements you hold (please check all that apply)

• Hazardous Materials

• Tanker Vehicle

• Bus passenger

• School Bus

• Double/Triple Trailers

• Combination HazMat/Trailer

• Other _____________

5. Are you an owner operator? (please check) ______ Yes ______No

6. Approximately how many hours do you drive per week? __________ hours

7. Approximately how many miles do you drive per week? __________ miles

8. Over the past three years, have you had any crashes in a commercial vehicle?

_______ Yes _______ No (If no, please skip to question 9)

If yes, state the number of crashes in each category over the past three years:

_______ Total crashes

_______ Preventable Crashes

_______ Injury Crashes

_______ Fatal Crashes

9. Over the past three years, have you had any moving violations in your commercial vehicle? (please check)

_______ Yes _______ No (If no, skip to question 10)

If yes, state the violation type for each crash over the past three years. Each row is a different violation: thus, if you had two violations you would complete two rows, one for each violation.

Violation Number	Violation Type (e.g., speeding, tailgating, signal violation, etc.)
1
2
3
4
5
6
7

10. How many nights per week do you typically return home after a route?

___________ nights per week

11. What are the typical routes you drive your commercial vehicle? (please check one)

• Local/ Delivery (less than 50 miles per trip)

• Short-haul/ Regional (50 – 499 miles per trip)

• Long-haul/ National (500 + miles per trip)

• Other _______________

Daily Routines

1. Do you typically consume caffeine? If yes, indicate the average amount consumed below.

o No

o Yes (If yes, for all categories that apply, indicate amount consumed in a typical day.)

Coffees _______ cups per day

Cola drinks _______ drinks per day

Energy drinks _______ drinks per day

Caffeine pills _______ pills per day

Caffeine gum _______ sticks/pieces per day

Tea (not herbal) _______ cups per day

2. If yes, please state how many hours ago you consumed your last caffeinated substance. ____ hours ago

Sleep Schedule

1. Approximately, how many hours of sleep did you get last night? ____ hours

2. Approximately, how many hours of sleep did you get two nights ago? ____hours

3. Approximately, how many hours of sleep did you get three nights ago? ____hours

Please indicate your current sleepiness level on the following scale (please check one):

KAROLINSKA SLEEPINESS SCALE (KSS)

• Extremely Alert.................................................................................. 1

• Very Alert.......................................................................................... 2

• Alert....................................................................................................3

• Rather Alert........................................................................................ 4

• Neither alert nor sleepy...................................................................... 5

• Some signs of sleepiness....................................................................6

• Sleepy, but no effort to keep awake................................................... 7

• Sleepy, but some effort to keep awake.............................................. 8

• Very sleepy, great effort to keep awake, fighting sleep..................... 9

• Extremely sleepy, can’t keep awake..................................................10

Driver Health

1. Has a physician informed you that you have any of the following conditions? (Mark all that apply to you.)

o Sleep apnea

o Diabetes

o High blood pressure

o Insomnia

2. Do you use any of the following? (Mark all that apply to you)

o CPAP for sleep apnea

o Medication for diabetes

o Medication for high blood pressure

o Medication for insomnia

3. How often do you experience pain of any kind during a typical daily work shift? (Check only 1 box)

o 0-5% of shift

o 5-25% of shift

o 25-50% of shift

o 50-75% of shift

o 75% or more of shift