NHTSA Form 1172 Debriefing Questionnaire for Instrumented On-Road Study

OMB Control No. 2127-xxxxx

Expiration Date xx/xx/xxxx

Debrief

Experience riding with the equipment

Please note 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 2117-xxxx. Public reporting for this collection of information is estimated to be approximately 15 minutes per response, 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.

1. During the period you participated in this study, how often were you under the influence of drugs or alcohol while riding?

Approximately ______ times.

2. How often do you wear your safety belt when driving a car?

Never

Rarely

Occasionally

Often

Always

3. On average, how much stress did you feel during the period you participated in this study?

No Stress

Slightly stressed

Moderately stressed

Very stressed

Extremely stressed

4. To what degree do you think your riding was altered or different because you were participating in this study and your riding was monitored?

Not altered

Slightly altered

Moderately altered

Very altered

Extremely altered

5. In what way would you say it was altered?

6. How would you rate how safely you rode during the period you participated compared to your riding before your involvement?

Much Less Safely

Moderately less safely

Neither

Moderately more safely

Much more Safely

7. How would you rate your riding compared to other riders?

Much worse	Moderately worse	Neither	Moderately better	Much better

8. How would you rate your overall experience of participating in this study?

Very bad

Bad

Neither

Good

Very good

9. Is there anything in particular that you would like to bring to our attention?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

10. How would you rate your experience with having your bike instrumented?

Very bad

Bad

Neither

Good

Very good

11. Is there anything in particular that you would like to bring to our attention?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

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NHTSA Form 1172