Driving Survey

Study/Subject:

Date: _____________

Attachment 2

Driving Survey

OMB Control #: 0925-xxxx Expiration Date: mm/dd/yyyy

Public reporting burden for 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 and reviewing 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx). Do not return the completed form to this address.

Driving Survey

As part of this study, it is useful to collect information describing each participant. The following questions ask about you and your health, your driving patterns, and your alcohol consumption. Please read each question carefully. If something is unclear, ask the researcher for help. Your participation is voluntary and you have the right to omit questions if you choose. Please remember that all of your answers will be kept confidential.

Background Information

1) What is your birth date?	_______ /	_______ /	_____________
	Month	Day	Year

2) What age are you today? __________

3) What is your gender?

 Male

 Female

4) What is your marital status? (Check only one)

 Single, never married

 Married

 Domestic Partnership

 Separated or Divorced

 Widowed

5) What was your total household income last year? (Check only one)

 $0- $24,999

 $25,000- $29,999

 $30,000 - $34,999

 $35,000 - $39,999

 $40,000 - $49,999

 $50,000 - $59,999

 $60,000 - $69,999

 $70,000 - $79,999

 $80,000 - $89,999

 $90,000 - $99,999

 $100,000 or more

6) What is your present employment status? (Check only one)

 Unemployed

 Retired

 Work part-time

 Work full-time

 None of the above

7) Are you Hispanic or Latino?

 Yes, Hispanic or Latino

 No, not Hispanic or Latino

8) What is your race?

 American Indian/Alaska Native

 Asian

 Black/African American

 Native Hawaiian/Other Pacific Islander

 White

9) What is the highest level of education that you have completed? (Check only one)

 Primary School

 High School Diploma or equivalent

 Technical School or equivalent

 Some College or University

 Associate’s Degree

 Bachelor’s Degree

 Some Graduate or Professional School

 Graduate or Professional Degree

Driving Experience

10) How old were you when you started to drive, even if you were not yet licensed? ___ years of age

11) For which of the following do you currently hold a valid driver’s license within the United States? (Check all that apply)

	Vehicle Type	Year When FIRST Licensed (May be Approximate)
	Passenger Vehicle License	____ ____ ____ ____
	Commercial Truck License	____ ____ ____ ____
	Motorcycle License	____ ____ ____ ____
	Other: ______________________	____ ____ ____ ____
	Other: ______________________	____ ____ ____ ____

12) How often do you drive? (Check the most appropriate category)

 Less than once weekly

 At least once weekly

 At least once daily

13) Approximately how many miles do you drive per year? ______________

14) How frequently do you drive in the following environments? (Check only one for each environment)

	Never	Yearly	Monthly	Weekly	Daily
Residential					
Business District					
Rural Highway (e.g., Route 6)					
Interstate (e.g., Interstate 80)					
Gravel Roads					

15) How comfortable do you feel when you drive in the following conditions or perform the following maneuvers? (Check the most appropriate answer for each condition)

	Very Uncomfortable	Slightly Uncomfortable	Slightly Comfortable	Very Comfortable	Not Applicable
Highway/freeway					
After drinking alcohol					
With children					
High-density traffic					
Passing other cars					
Changing lanes					
Making left turns at uncontrolled intersections					

Health Status

16) How often do you experience motion sickness? (Circle only one)

0

1

2

3

4

5

6

7

8

9

10

Never Always

17) How severe are your symptoms when you experience motion sickness (Circle only one)

0

1

2

3

4

5

6

7

8

9

10

None Severe

18) Have you taken any medication in the past 48 hours? (Check only one)

 No

 Yes (Please list all) ___________________________________________________

_____________________________________________________________________

19) What is your normal bedtime (hour of the day)? __________________________________

Crashes

20) In the past five years, have you been involved in a crash while driving a motor vehicle in which there was damage to your vehicle or another vehicle?

 Yes (Continue with 20A)

 No (IF NO, Survey is Complete)

20A) If you answered yes to number 20, how many times have you been the driver of a car involved in a crash?

 1

 2

 3

 4 or more

20B) If you answered yes to number 20, were any of these crashes the result of any of the following behaviors:

	Yes	No
Nodding off/struggling to keep eyes open		
After drinking alcohol		
Talking on cell phone		
Texting on cell phone		
Talking to passenger		
Eating or drinking		
Looking at map/GPS		
Using handheld device such as iPod		
Sending or receiving emails		
Reading		

20C) If you answered yes to number 20, were any of these crashes the result of Other/Anything Else: _________________________________________

The End