Form NHTSA Form 1240 NHTSA Form 1240 Recruitment Form

OMB#: 2127-xxxx

Expiration Date:xx/xx/xxxx

Mild Cognitive Impairment and Driving Performance Questionnaire

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 interview, 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, W51-316, 1200 New Jersey Ave, S.E., Washington, DC, 20590

Qualifying Questions:

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

2. Do you have a valid driver’s license, and if so, when does it expire?

3. What is your date of Birth?

4. About how many times per typical week do you start your car to drive?

5. Have you been diagnosed with any medical condition for which your doctor has advised you to limit or adjust your driving habits? 

6. Do you use adaptive controls in your car?

7. Will you be spending the next two or three months in the area?

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.

NHTSA Form 1240