OMB Control No. 2127-XXXX
Expiration Date xx/xx/xxxx
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 7 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
Participant Eligibility Questionnaire:
What is your age: ___
__18 to 29
__30 to 49
__50 to 69
__70 and older
Are you legally blind?
__Yes
__No
Do you travel and cross streets without assistance from another person?
__Yes
__No
How often (how many times per week) do you cross streets without assistance from another person?
__less than 10 street crossings per week
__between 10 and 20 street crossings per week
__more than 20 street crossings per week
Do you consider yourself to have normal hearing in both ears (without hearing aids)?
__Yes
__No
Do you have normal manual dexterity in both hands (for prompt button pressing)?
__Yes
__No
Are you a Volpe Center employee?
__Yes
__No
NHTSA Form 1173
| File Type | application/msword |
| File Title | Participant Eligibility Questions: |
| Author | vegal |
| Last Modified By | walter.culbreath |
| File Modified | 2012-06-20 |
| File Created | 2012-06-20 |