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
What is your age? __________ (yrs)
What is your gender?
Female
Male
Other
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
Is English your primary language (please check)? ___ Yes ___ No
If no, please indicate your primary language here _____________________
What is your height in feet _______(ft) and inches _______ (in)?
What is your weight in pounds __________ (lbs.)?
What is your race?
American Indian or Alaska Native
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
Other ________________
Driving Experience
How long have you been driving commercial vehicles?
_____years _____ months
Are you currently employed as a commercial motor vehicle driver?
____ Yes ___ No
What class commercial driver’s license do you currently hold? _____________
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 _____________
Approximately how many hours do you drive per week? __________ hours
Approximately how many miles do you drive per week? __________ miles
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
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 |
|
How many nights per week do you typically return home after a route?
___________ nights per week
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
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
If yes, please state how many hours ago you consumed your last caffeinated substance. ____ hours ago
Sleep Schedule
Approximately, how many hours of sleep did you get two nights ago? ____hours
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
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
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
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
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Matthew Camden |
| File Modified | 0000-00-00 |
| File Created | 2023-10-02 |