Form NHTSA Form 1186 NHTSA Form 1186 Older Driver Compliance with License Restrictions Partic

OMB No. 2127-xxxx

Expiration Date xx/xx/xxxx

Older Driver Compliance with License Restrictions Participant Screening Questionnaire

This collection of information is voluntary and will be used to assist in the development of motor vehicle standards and traffic safety programs designed to reduce the number of traffic-related injuries and deaths. 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

Qualifying Questions:

1. Do you own or have possession and use of a car? (Qualifying)

2. Are you licensed to drive in Virginia? (Qualifying)

3. What is your driver license expiration date; is your license revoked or suspended? (Qualifying)

4. What is your date of Birth? (Qualifying)

5. What license restrictions are listed on the reverse side of your driver license? (Qualifying)

6. About how many times per typical week do you start your car to drive? (Qualifying)

7. Have you ever received a diagnosis of dementia? (Qualifying)

8. Will you be spending the next two or three months in the area? (Qualifying)

Following qualification of respondents to participate in the research effort, and after answering all questions each may have regarding the study, we propose to ask each qualified respondent if he or she wishes to join the study. If yes, we propose to ask several more logistic questions to facilitate scheduling and successful installation of the vehicle instruments. Those specific questions follow:

9. Are you interested in participating in this study?

10. What is the make, model, and year of car? (necessary to plan install)

11. What is your tag number (needed to identify the specific vehicle for install)

NHTSA Form 1186