NHTSA Form 1168 Candidate Participant Screening

OMB Control No. 2127-(pending)
Expiration Date (pending)

Candidate Participant Screening Questions
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to
a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act
unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this
information collection is 2127-XXXX. Public reporting for this collection of information is estimated to be approximately 15
minutes, including the time for reviewing instructions, completing and reviewing the collection of information. All
responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance
Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

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Subject Number (selection by principal investigator)
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Candidate Number
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Date Scheduled
Call Log (Track the time and date of each call attempt made):
NAME (first M.I. last)
PHONE - DAY
PHONE - Cell Phone
GENDER (M / F)
BIRTHDATE (mm/dd/yyyy)
AGE (office note: must be at least 18 years old to participate) 18 yrs +
HEIGHT (needed to pre-adjust in-vehicle equipment before participant arrival)
I will now ask you some questions about your medical history and present condition. You
can refuse to answer any question. Please answer yes or no.
Are you able to drive without the use of assistive devices?
Do you have any health conditions that affect driving ability?
Are you taking any medications that may impact your driving ability, such as by causing
drowsiness?
Have you ever had a concussion, brain injury, or other injury resulting in decreased motor control
or cognitive ability?
Do you currently have any medical condition that might affect your ability to concentrate while
driving, such as Attention Deficit Hyperactivity Disorder (ADHD), depression, anxiety, or
claustrophobia? (If yes, please explain.)
Do you suffer from any heart conditions such as: Disturbance of heart rhythm? Had a heart attack
in the last 6 months? Had a pacemaker implant within the last 6 months? (If yes, please
describe)
Do you have uncontrolled high blood pressure?
Do you have diabetes for which insulin is required?
Are you prone to any episodic health problems that may suddenly and unexpectedly affect you,
such as seizures, epilepsy, or narcolepsy?

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Availability

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What days of the week would you be available to participate in a 60-minute session?
What time of day would you prefer to participate in testing (Morning or Afternoon, reference their
recruitment letter responses)?
How long would you like to be considered for this study? I.e., how long will your availability
continue?
OK, that's all of our questions. Thank you! We will call you if you have been selected for
participation. We will provide additional information at that time.

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NHTSA Form 1168

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CALL BACK FOR SCHEDULING APPOINTMENT
PI will determine which subjects are selected for participation.
Office Use Below
WHO CONTACTED THE SUBJECT? (personnel name)
APPOINTMENT CONFIRMATION CALL BACK
Hi this is _________ from __________. This is a call back to notify you that you have been
selected to participate in our driving study discussed in earlier phone conversations with
___________. I have several additional questions and then I will schedule a test session.
Are you currently taking any over-the-counter cold or allergy medications?
Are you taking any prescription drugs that may affect your driving (such as those that advise you
not to work with heavy machinery or operate a vehicle)?
SCHEDULING PARTICIPANTS
I would like to schedule an appointment with you at this time. The first available openings are:
____________(calendar of events needed w/ date and time frame - try to utilize previous call input
for choices, before calling). Do any of those dates and times work for you? (If yes, schedule. If
no, then offer next available set of times...perhaps by week, until scheduled. If no good dates,
find a time when best for them and say we will see what we can do and call back later.)
(Appointment Confirmation) Ok. I have you scheduled for _________________. Please arrive
on time. There is no need to arrive early. Arriving early or late can potentially cause overlap with
other scheduled appointments.
*EMAIL ADDRESS* May we use your E-mail address to help with scheduling?
Also, please be sure to bring your valid, U.S. driver's license to the appointment for identification
purposes. Dress comfortably for driving and weather conditions and wear comfortable driving
shoes. Do not bring another guest with you, unless prior arrangements have been made with us.
Note that your personal cell phone must be turned off while you are participating in this study.
Please refrain from drinking alcohol or taking non-prescription drugs for at least the 24
hours preceding the session. Do you understand these requirements? Record "Yes" or "No"
Cameras, firearms, and alcoholic beverages are not permitted at TRC.
Give directions to data collection site
For the purposes of calculating mileage payment, where will you be coming from to attend
the appointment (home / work address)?
Do you have any questions at this time?
If you have any questions before your scheduled date, please feel free to call me at
__________________ (give phone number / extension)
If you need to cancel or reschedule your appointment, please try to call at least 24 hours in
advance. Otherwise, we look forward to seeing you on (date at time) ___________,

NHTSA Form 1168