Form NHTSA Form 1170 NHTSA Form 1170 Screener for Instrumented On-Road Study of Motorcycle Ri

OMB Control No. 2127-xxxxx

Expiration Date xx/xx/xxxx

Screening Questionnaire

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 2127-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.

Note to Researcher:

Upon establishing phone contact with a potential participant, please, read the following Introductory Statement, followed by the questionnaire. Regardless of how contact is made, this questionnaire must be administered verbally before a decision is made regarding suitability for this study. Do not place any participant information on this questionnaire; it should only be used to record participant answers. Once eligibility has been determined (i.e., the participant answers comply with all the screening criteria) and you’ve recorded the participant information on the last page, discard the rest of this questionnaire.

Introductory Statement:

After prospective participant calls or you call them, use the following script as a guideline in the screening interview.

Hello, my name is ______ and I am a researcher with the Virginia Tech Transportation Institute in Blacksburg, VA. We are currently recruiting motorcycle riders to participate in a research study. During this call, we would like to determine if you might be interested in hearing more about the study and if you have possible interest in participating. In the event you are interested, we will provide you with further information either by mail or on our website.

Would it be okay to tell you a little more about the study?

Study

Participants in the study will have sensors and cameras installed on their bike for a year. The data will be collected as they ride. The data will be used by researchers to understand motorcycle riding in the context of surrounding conditions including weather, the roadway, and other roadway users.

VTTI and NHTSA Background

This study is run by the Virginia Tech Transportation Institute, or VTTI, which is a part of Virginia Tech. VTTI has been doing studies of this sort for over ten years, with cars, tractor trailers, and motorcycles. The Institute is experienced with installing sensors on vehicles and later removing them without damage. We have developed the sensors and cameras, as well as the garage procedures, specifically for motorcycles. The project is being funded by the National Highway Traffic Safety Administration. The purpose of this work is to understand riding within the surrounding roadway system, what works well for riders and what causes problems, and to use this understanding to reduced rider fatalities and injuries.

Privacy

The data collected on your motorcycle will be encrypted as it is collected and can only be decrypted by VTTI. From the start of your involvement, your name will not be associated with the riding data. As the data are decrypted, VTTI will store it so as to support studying motorcycle riding while preventing identification of participants. In addition, your participation will be covered by a National Institutes of Health Certificate of Confidentiality. With this certificate, researchers and study sponsors cannot be forced to disclose information that may identify you, even by a court subpoena, in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings.

Pay

You will receive a total of $500.00 for participating. The $500 will be paid to you in three payments by direct deposit. The first ($150) after your motorcycle is instrumented, second after your first six months ($150) of riding with the instrumentation, and the third payment of $200 after completion of the 12^th month of participation and your bike has been deinstrumented.

At this time, I would like to collect information we will use to see if you are eligible to participate, but before I do I would like to answer any questions you have.

Answer questions.

Does this sound interesting to you?

If No:

Thank you for your time. If you have any questions in the future related to this study or this call, you may reach me at 800-997-7836.

If Yes:

First, I would like to collect some information from you to determine if you are eligible to participate. This will take up to 15 minutes of your time. If there is a question you are uncomfortable with, you do not have to answer it. Do I have your verbal permission to ask you these questions?

• Yes

• No (Ineligible)

Upon receiving ineligible response, please STOP and tell them they are not eligible for the study based on their answer. Refer to Criteria for Participation for additional information. A sample script is provided at the end of this document once eligibility (or ineligibility) has been determined.

1. Gender

• Male

• Female

2. How old are you? ____ years old (Ineligible under 18 years of age.)

3. Do you have a valid motorcycle license/endorsement?

• Yes

• No (Ineligible)

4. Do you have a street motorcycle that you own and will own and ride regularly for the next 12 months?

• Yes

• No (Ineligible)

5. If we provide more details about the sensors and cameras, are you possibly willing to have that motorcycle instrumented for this study?

• Yes

• No (Ineligible)

6. What is the make/model/year/displacement of this motorcycle?

Make _______

Model _______

Year _______

Size/Displacement _________

Ineligible if not in list of motorcycle / models below:

e.g., Kawasaki Versys 2009-2011

7. Do you currently carry at least liability insurance for this motorcycle?

• Yes (Mention that we will require proof of insurance during orientation)

• No (Ineligible)

8. We will require proof of insurance during the orientation. Are you able to provide us with this information?

• Yes

• No (Ineligible)

9. How would you describe the mechanical condition of this motorcycle?

• Excellent – Always starts, runs great, like new.

• Good – Always starts, runs well, has some miles on it.

• Fair – Occasional minor trouble starting but runs well.

• Poor– Often trouble starting or requires attention to keep running. (Ineligible)

10. Do you expect anyone else will operate this motorcycle regularly during this period?

• Yes (Ineligible)

• No

11. Are you eligible for employment in the U.S.? (Please note that we are NOT offering employment to you.)

• Yes

• No (Ineligible)

12. Are you comfortable reading and speaking English?

• Yes

• No (Ineligible)

13. Please note that for tax recording purposes, the fiscal and accounting services office at Virginia Tech (also known as the Controller's Office) requires that all participants provide their social security number to receive payment for participation in our studies. You do NOT need to provide it now, but are you willing to provide us with your social security number?

• Yes

• No (Ineligible)

I now want to get an idea of how frequently you ride, and how long you’ve been riding. Please first describe how often you ride and how long you’ve been riding in your own words, then I will ask some follow up question to clarify.

Below are examples of follow-up questions to ask for clarification.

• Okay, in the last two years, it sounds like…?

Convert their phrasing into days/month and see if the amount sounds about right to them.

• Okay, it sounds like you started riding in the last two years?

Yes / No, longer

• Okay, going five years back, it sounds like…?

Convert their phrasing into days/month and see if the amount sounds about right to them.

• It sounds like you took a break from riding for a while. Help me figure out how long ago you start riding again..

Determine if they resumed riding in the last two years

• How many miles would you say you’ve ridden in the past year?

For new/returning riders, determine if they have ridden <2,000 miles in the past year

• Do you have experience riding motorcycles off-road?

For new riders, determine if they have >2 years of experience riding off-road

Use the following guidelines to categorize what the potential participant has reported.

Novice

If they’ve first started riding in the last two years

Returning

If they rode some more than five years ago, and have just gotten back riding in the last two years.

Experienced

If they’ve been riding for the past five years or more

Frequency

Low Frequency ≤2 days/month

Medium Frequency 3-7 days/month

High Frequency ≥8 days/month

Based on the answers above, potential participants will be categorized using the following descriptions.

Novice

Novice High Frequency – I rode for the first time in the last two years. Currently I ride a couple days a week or more during the riding season (approximately 8 days per month or more). In the past year, I have ridden 2,000 miles or fewer. I don’t have more than two years of experience riding off-road.

Novice Medium Frequency – I rode for the first time in the last two years. Currently I probably ride between 3 and 7 days a month. In the past year, I have ridden 2,000 miles or fewer. I don’t have more than two years of experience riding off-road.

Novice Occasional - I rode for the first time in the last two years. I currently ride a few days a month during the riding season (less than three days per month).

Novice Not Riding – I learned to ride, but don’t ride right now.

Experienced

Experienced High Frequency – I’ve been riding a street motorcycle 8 days a month during the riding season for the last five years.

Experienced Low Frequency – I’ve been riding a street motorcycle less than 8 days a month during the riding season for the last five years.

Experienced Not Riding – I rode frequently for several years when I was younger, but I don’t ride right now.

Returning

I rode when I was younger (5+ years ago), then stopped. I just got back into riding in the last two years. I currently ride 3 or more days a month during the riding season. In the past year, I have ridden 2,000 miles or fewer.

The following matrix will be used to determine eligibility.

Riders who do not fit into the categories in the matrix are also ineligible.

14. Please briefly describe any modification you have done to your motorcycle in the area of the handlebars, front forks, gauges, or rear wheel. Let me check some specifics:

1. trim accessories

2. brake levers/pedals

3. floor boards

4. GPS mounting

5. exhaust modifications

6. fairings

7. bags/luggage

8. anything else?

(Ineligible if modification incompatible with current available instrumentation.)

15. How did you hear about our study? Did you receive a letter, word of mouth from someone that did receive a letter, email list, etc?

Eligibility Determination

If the Participant is NOT Eligible:

Unfortunately, for this study we are not able to include participants …

In your age group

Who ride ___________ bike type

Who don’t have motorcycle licenses.

Etc.

We really appreciate your time. We expect to be involved in different studies in the future. If it is okay with you, we’d like to keep you on the list of possible participants for future studies..

If the Participant’s demographics are close or if they are in a cell that is already filled:

At this time, recognizing that everyone is different, it appears that we have enough participants that match your demographic. Things sometimes change though, for example someone might drop out, or numbers of people we recruit might change. If it is okay with you, we’ll keep you included as a possible participant.

If the Participant IS Eligible:

Thank you for answering these questions. Okay, based on your answers, you meet the study requirements. I would like to provide you with more detailed information about the study so you can decide if you want to participate. To do this, I would like to obtain your contact information so that we can provide you with the information and follow-up after you have looked at it. Please note that we will likely not be able to have everyone participate who is interested, so you may end up receiving the materials and being willing to participate, but we cannot include you in this study. If this happens, we will hopefully be able to include you in future studies.

1. Name: __________________

2. Do you have access to the internet?

• Yes

• No

If yes,

I would like to provide you with a website that you can visit to learn more about the study, see pictures of instrumented bikes, and read over the Informed Consent Form. [When they have something to write with, give them the web address].

If no: What is your mailing address?

Mailing address:

Finally, I’d like to get your phone numbers to follow-up with you.

3. Phone numbers:

   1. Home : ______________________________

   2. Cell Phone: ___________________________

   3. Work Phone: ___________________________

4. Which is the best number to use to contact you? __________________

5. When would be good to call? Make as soon as convenient. If unsure, suggest three days.? ___________________________________________

After having looked at the materials, feel free to contact me with questions or to accept or decline participation. The best number to reach me at is 800-xxx-xxxx. We may also be getting back in touch with you in a week or so if we haven’t heard from you to make sure you were able to access the project website. Thank you for your help!

******************************************************************************

*When calling to schedule appointment, remind participant to bring license, registration, and insurance with them to the installation site.

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NHTSA Form 1170