NHTSA 1198 Consent Form - English (also attached as part of questio

Appendix A – Consent Form (English)

Form: NHTSA 1198

OMB Control NO. XXXXXX

Expiration Date: XX/XX/XXXX

The Idaho Driving Safety Survey

The National Highway Traffic Safety Administration (NHTSA) and the State of Idaho are inviting you to participate in a research survey about speeding and traffic safety conducted for NHTSA and the State by Battelle. This NHTSA survey aims to collect information on individual attitudes, beliefs, and habits associated with driver speeding behavior in Idaho.

If you choose to participate, you will be asked questions about your opinions on driving and driving safety, how you drive, and a few questions about things like age and gender for statistical purposes.

You are one of approximately 2100 randomly selected residents of Idaho who have been asked to participate in this survey. We need your response to help make this study representative of the diverse experiences of all drivers in the state. It will take about 20-30 minutes to complete, and you have received $5.00 in your survey packet to thank you for your time.

Battelle and NHTSA will have access to the survey data, but Battelle and NHTSA will never have access to your name, address or any other information that personally identifies you. The State of Idaho is mailing out the survey questionnaires, but they will never have access to your survey data.

It is also important that you know:

• There are no right or wrong answers.

• Your responses will be treated in a secure and confidential manner.

• Survey reports will present all findings as a whole, so individual responses cannot be identified.

• You might be uncomfortable answering some of these questions.

• Your participation in this survey is voluntary. You may skip any questions that you do not want to answer or stop answering at any point.

• If you have questions about the study please call our toll-free number 1-xxx-xxx-xxxx.

If you have questions about your rights as a research participant, please call the toll-free number, 1-877-810-9530, ext. 500.

This collection of information is voluntary and will be used to develop safety measures intended to reduce traffic crashes and fatalities. Public reporting burden is estimated to average 21 minutes per response, including the time for reviewing instructions searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 2127-XXXX (state OMB #). 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 Avenue, SE, Washington, DC 20590.