Appendix B: Copy of Questionnaires Subject ID# ___________ Please answer each of the following items.
Driving History – Subject Interview In the past year, how many moving or traffic violations have you had? ___________ What type of violation was it? (1). ____________________ (2). ____________________ (3). ____________________ (4). ____________________ (5). ____________________ In the past year how many accidents have you been in? ________________ For each accident indicate the severity of the crash (select highest) a. Injury b. Tow-away (any vehicle) c. Police-reported d. Damage (any), but no police report Using the diagram indicate each of the following: Category, Configuration, Accident type
Comments: ______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Health Assessment To the Participant: Please note that your responses to the following questions will in no way
If yes to any of the above, please explain? _____________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ___________________
If yes, please list them. ____________________________________________________ _____________________________________________________________________ ______________________________________________________________________ _______
Please answer each of the following items as honestly as possible. Please read each item carefully and then circle the answer you choose on the form. If none of the choices seem to be your ideal answer, then select the answer that comes closest. THERE ARE NO RIGHT OR WRONG ANSWERS. Select your answers quickly and do not spend too much time analyzing your answers. If you change an answer, erase the first one well. 1. I drive when I am angry or upset. A. Never B. Rarely C. Sometimes D. Often E. Always 2. I lose my temper when driving. A. Never B. Rarely C. Sometimes D. Often E. Always 3. I consider the actions of other drivers to be inappropriate or “stupid.” A. Never B. Rarely C. Sometimes D. Often E. Always 4. I flash my headlights when I am annoyed by another driver. A. Never B. Rarely C. Sometimes D. Often E. Always 5. I make rude gestures (e.g., giving “the finger,” yelling curse words) toward drivers who annoy me. A. Never B. Rarely C. Sometimes D. Often E. Always 6. I verbally insult drivers who annoy me. A. Never B. Rarely C. Sometimes D. Often E. Always 7. I deliberately use my car/truck to block drivers who tailgate me. A. Never B. Rarely C. Sometimes D. Often E. Always 8. I would tailgate a driver who annoys me. A. Never B. Rarely C. Sometimes D. Often E. Always 9. I “drag race” other drivers at stop lights to get out front. A. Never B. Rarely C. Sometimes D. Often E. Always 10. I will illegally pass a car/truck that is going too slowly. A. Never B. Rarely C. Sometimes D. Often E. Always 11. I feel it is my right to strike back in some way, if I feel another driver has been aggressive toward me. A. Never B. Rarely C. Sometimes D. Often E. Always 12. When I get stuck in a traffic jam I get very irritated. A. Never B. Rarely C. Sometimes D. Often E. Always 13. I will race a slow moving train to a railroad crossing. A. Never B. Rarely C. Sometimes D. Often E. Always 14. I will weave in and out of slower traffic. A. Never B. Rarely C. Sometimes D. Often E. Always 15. I will drive if I am only mildly intoxicated or buzzed. A. Never B. Rarely C. Sometimes D. Often E. Always 16. When someone cuts me off, I feel I should punish him/her. A. Never B. Rarely C. Sometimes D. Often E. Always 17. I get impatient and/or upset when I fall behind schedule when I am driving. A. Never B. Rarely C. Sometimes D. Often E. Always 18. Passengers in my car/truck tell me to calm down. A. Never B. Rarely C. Sometimes D. Often E. Always 19. I get irritated when a car/truck in front of me slows down for no reason. A. Never B. Rarely C. Sometimes D. Often E. Always 20. I will cross double yellow lines to see if I can pass a slow moving car/truck. A. Never B. Rarely C. Sometimes D. Often E. Always 21. I feel it is my right to get where I need to go as quickly as possible. A. Never B. Rarely C. Sometimes D. Often E. Always 22. I feel that passive drivers should learn how to drive or stay home. A. Never B. Rarely C. Sometimes D. Often E. Always 23. I will drive in the shoulder lane or median to get around a traffic jam. A. Never B. Rarely C. Sometimes D. Often E. Always 24. When passing a car/truck on a 2-lane road, I will barely miss on-coming cars. A. Never B. Rarely C. Sometimes D. Often E. Always 25. I will drive when I am drunk. A. Never B. Rarely C. Sometimes D. Often E. Always 26. I feel that I may lose my temper if I have to confront another driver. A. Never B. Rarely C. Sometimes D. Often E. Always 27. I consider myself to be a risk-taker. A. Never B. Rarely C. Sometimes D. Often E. Always 28. I feel that most traffic “laws” could be considered as suggestions. A. Never B. Rarely C. Sometimes D. Often E. Always Sleep Hygiene Questionnaire Using the following rating scale, to what extent do you currently experience the following? None Moderate Severe Daytime sleepiness 1 2 3 4 5 6 7 8 9 10 Snoring 1 2 3 4 5 6 7 8 9 10 Difficulty Falling Asleep 1 2 3 4 5 6 7 8 9 10 Difficulty Staying Asleep 1 2 3 4 5 6 7 8 9 10 Difficulty Waking Up 1 2 3 4 5 6 7 8 9 10 Daytime Sleepiness 1 2 3 4 5 6 7 8 9 10 Obtain Too Little Sleep 1 2 3 4 5 6 7 8 9 10 Read through the following questions carefully and answer each as accurately as possible: 1. When you are working: what time do you go to bed ____:____ a.m./p.m. and wake up ____:____ a.m./p.m. 2. When you are not working: what time do you go to bed ____:____ a.m./p.m. and wake up ____:____ a.m./p.m. 3. Do you keep a fairly regular sleep schedule? Yes_____ No_____ 4. How many hours of actual sleep do you usually get? ________ 5. Do you consider yourself a light, normal, or heavy sleeper? _______________ 6. Do you feel uncomfortably sleepy during the day? never_____ every day_____ more than once per week_____ once per week _____ a few times a month _____ once a month or less_____ 7. Do you ever have an irresistible urge to sleep or find that you fall asleep in unusual/ inappropriate situations? never_____ every day_____ more than once per week_____ once per week _____ a few times a month _____ once a month or less_____ 8. Do you usually nap during the day (or between major sleep periods)? Yes_____ No_____ 9. Do you drink caffeinated beverages (coffee, tea, Coca-Cola, Mountain Dew, Jolt Cola)? Yes_____ No_____ 10. If yes, how many cups/glasses per day? __________________ 11. How often do you drink alcohol? never_____ every day_____ more than once per week_____ once per week _____ once a month or less_____ 12. Do you smoke cigarettes, cigars, pipe or chew or snuff tobacco? Yes_____ No_____ 13. If yes, how often? __________________________ PRIMARY SLEEP DISORDERS 14. Have you ever been diagnosed with or suffer from any of the following sleep disorders? Narcolepsy Yes No Sleep Apnea Yes No Periodic Limb Movement Yes No Restless Leg Syndrome Yes No Insomnia Yes No Driver Stress Inventory Please answer the following questions on the basis of your usual or typical feelings about driving. Each question asks you to answer according to how strongly you agree with one of two alternative answers. Please read each of the two alternatives carefully before answering. To answer, circle the number which expresses your answer most accurately. Example: Are you a confident driver? 1 2 3 4 5 6 7 8 9 10 Not at all Very Much
1 2 3 4 5 6 7 8 9 10 Very Much Not at all
1 2 3 4 5 6 7 8 9 10 Very Rarely Very Often
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Very rarely Very often
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Very Much Not at all
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Useful Unnecessary
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Not at all Very much
1 2 3 4 5 6 7 8 9 10 Very much Not at all
1 2 3 4 5 6 7 8 9 10 Very much Not at all
a) More uncomfortable 1 2 3 4 5 6 7 8 9 10 No change physically (e.g., headache or muscle pains) b) More drowsy or sleepy 1 2 3 4 5 6 7 8 9 10 No change c) Maintain speed of reaction 1 2 3 4 5 6 7 8 9 10 Reactions to other traffic becomes increasingly slower d) Maintain attention to road-signs 1 2 3 4 5 6 7 8 9 10 Become inattentive to road-signs e) Normal vision 1 2 3 4 5 6 7 8 9 10 Vision becomes less clear f) Increasingly difficult to 1 2 3 4 5 6 7 8 9 10 judge your speed judgment of speed g) Interest in driving does not 1 2 3 4 5 6 7 8 9 10 Increasingly change bored and fed up h) Passing becomes increasing- 1 2 3 4 5 6 7 8 9 10 No change ly risky and dangerous Life Stress Inventory
Please read through the following events carefully. Mark each event which occurred within the past year. ____ Death of spouse or parent ____ Divorce ____ Marital separation or separation from living partner ____ Jail term ____ Death of close family member ____ Personal injury or illness ____ Fired from job ____ Marital or relationship reconciliation ____ Retirement ____ Change in health of family member ____ Pregnancy ____ Sex difficulties ____ Gain of new family member ____ Business readjustment ____ Change in financial state ____ Death of close friend ____ Change to different line of work or study ____ Change in number of arguments with spouse or partner ____ Mortgage or loan for major purchase (home, etc.) ____ Foreclosure of mortgage or loan ____ Change in responsibilities at work ____ Son or daughter leaves ____ Trouble with in-laws/partner's family ____ Outstanding personal achievement ____ Mate begins or stops work ____ Change in living conditions ____ Marriage/establishing life partner ____ Change in personal habit ____ Trouble with boss ____ Change in work hours or conditions ____ Change in residence ____ Change in schools ____ Change in church activities ____ Change in recreation ____ Change in social activities ____ Minor loan (car, TV, etc) ____ Change in sleeping habits ____ Change in number of family get-togethers ____ Change in eating habits ____ Vacation ____ Christmas (if approaching) ____ Minor violation of the law |
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