Form NHTSA Form 1222 NHTSA Form 1222 Recruitment Questionnaire

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 10 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

DRIIVE Phase 2 Phone Screening Procedures

{Insert Study Description}

• Are you still interested in participating?

• If YES, continue with Inclusion Criteria

Inclusion Criteria ~ General Questions

Overview

Before this list of questions is administered, please communicate the following:

• There are several criteria that must be met for participation in this study. I will need to ask you several questions to determine your eligibility.

Proceed to Closing if an answer does not meet study criteria.

1. Do you possess a valid U.S. Drivers’ License?
   
   

2. How long have you been a licensed driver?

3. What restrictions do you have on your license?

4. How many miles do you drive per year?

5. Do you require any special equipment to help you drive such as pedal extensions, hand brake or throttle, spinner wheel knobs or other non-standard equipment?

6. How old are you?

General Questions Inclusion Criteria is met – proceed to Specific Questions Inclusion Criteria

Inclusion Criteria ~ Specific Questions Track A

Proceed to Closing if an answer does not meet study criteria.

1. What types of non-driving tasks do you engage in while operating motor vehicles?

Specific Inclusion Criteria is met – proceed to General Health Exclusion Criteria

Inclusion Criteria ~ Specific Questions Track B

Proceed to Closing if an answer does not meet study criteria.

1. How far do you live from University of Iowa Research Park which is North of the Coral Ridge Mall?

2. Are you able to attend two study visits after 7 pm and stay overnight without sleeping?

3. Are you able to refrain from caffeine after 12pm on the day of the overnight visit?

4. Are you able to abstain from driving for the day following your overnight drive?

5. Do you go to sleep and wake at approximately the same time every day?

6. Have you no reason to believe that you have might have obstructive sleep apnea?

7. Because we are conducting a study to determine how sleep impacts driving performance, the following questions ask you about your sleep patterns. Your answer will determine if you continue to meet the study qualifications.

• Administer Morning/Evening Survey

Specific Inclusion Criteria is met – proceed to General Health Exclusion Criteria

General Health Exclusion Criteria

1.1.1Overview

1.1.2Before administering this list of questions, please communicate the following:

2Because of pre-existing health conditions, some people are not eligible for participation in this study.

3I need to ask you several health-related questions before you can be scheduled for a study session.

4Your responses are voluntary and all answers are confidential.

5You can refuse to answer any questions

6No responses will be recorded.

• If a participant fails to meet one of the following criteria, proceed to the Closing

1) If the subject is female:

• Are you, or is there any possibility that you are pregnant? Or, are you currently breast feeding?

2) Have you been diagnosed with a serious illness?

3) Do you have Diabetes?

4) Do you suffer from a heart condition such as disturbance of the heart rhythm or have you had a heart attack or a pacemaker implanted within the last 6 months?

5) Have you ever suffered brain damage from a stroke, tumor, head injury, or infection?

6) Have you ever been diagnosed with seizures or epilepsy?

7) Do you have Ménière's Disease or any inner ear, dizziness, vertigo, hearing, or balance problems?

8) Do you currently have a sleep disorder such as sleep apnea, narcolepsy, or Chronic Fatigue Syndrome?

9) Do you have migraine or tension headaches that require you to take medication daily?

10) Do you currently have untreated depression, drug dependency, anxiety disorder, ADHD or claustrophobia?

11) Are you currently taking any prescription or over the counter medications?

12) Do you experience any kind of motion sickness?

13)  Have you experienced any pain from neck or back injuries within the last year?

NHTSA Form 1222 Page 4