Form NHTSA Form 1227 NHTSA Form 1227 Recruitment Form

OMB#: 2127-xxxx

Expiration Date:xx/xx/xxxx

Physical Fitness 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 drive your car?

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. If so, we propose to present the Phone-FITT items below.

Modified Phone-FITT Physical Activity Interview Questionnaire

I’d like to ask you about some physical activities and find out how often you do them, and for how long. First, I’d like you to think about activities you did around your home in a typical week in the last month.

Interviewer: Ask about each activity listed in the following charts. If respondent answers ‘yes’ to engaging in the activity, ask the follow-up questions about frequency and duration; otherwise skip to the next activity. Record answers in charts.

Household Activities

Activity	Participated?	Frequency (times per week)	Duration (Mark one only)
In a typical week in the last month, did you engage in __		How many times a week did you do this?	And about how much time did you spend on each occasion?
A. Light housework such as tidying, dusting, laundry, or ironing	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
B. Making meals, setting and clearing the table, and washing dishes	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
C. Shopping (for groceries or clothes, for example)	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
D. Heavy housework such as vacuuming, scrubbing floors, mopping, washing windows, or carrying trash bags.	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
E. Home maintenance such as painting, cutting grass, or other yard work (except for gardening which I’ll ask about later.)	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
F. Caring for another person (such as pushing a wheelchair or helping a person in or out of a chair or bed)	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +

Recreational and Conditioning Activities

Next I’d like to ask you about recreational or conditioning activities you may have engaged in, in a typical week in the last month.

Activity	Participated?	Frequency (times per week)	Duration (Mark one only)
In a typical week in the last month, did you engage in __		How many times a week did you do this?	And about how much time did you spend on each occasion?
G. Lifting weights to strengthen your legs	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
H. Other exercises designed to strengthen your legs (such as standing up/sitting down several times in a chair or climbing stairs)	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
I. Lifting weights to strengthen your arms or other exercises to strengthen your arms (such as wall push-ups)	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
J. Walking for exercise	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
K. Dancing	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
L. Swimming	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
M. Bicycling (either outdoors or indoors on a stationary bike)	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
N. Other aerobic exercise, (describe below) Include Zumba and Silver Sneakers, but also elliptical, rowing, stairstepper, etc.	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
O. Stretching or balance exercises, including activities such as yoga and tai chi (describe below)	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +

Seasonal Recreational and Other Physical Activities

Now I would like to ask you about a few specific activities that are seasonal, and about any other activities that you do.

Activity	Participated?	Frequency (times per week)	Duration (Mark one only)
In a typical week in the last month, did you ____		How many times a week did you do this?	And about how much time did you spend on each occasion?
P. Play golf □ Use cart □ Do not use cart	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
Q. Play tennis □ Singles □ Doubles	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
R. Gardening	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +

Do you participate in any other regular physical activities that I haven’t asked about?

If ‘yes,’ ask what the activity is, followed by how frequently and for how long. Repeat for up to 3 additional activities, recording answers in chart.

Activity	Participated?	Frequency (times per week)	Duration (Mark one only)
S. Other (write in below)	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
T. Other (write in below)	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +
U. Other (write in below)	□ Yes □ No		□ 1-15 minutes □ 16-30 minutes □ 31-60 minutes □ 1 hour +

Thank you very much for taking the time to complete this interview.

NHTSA Form 1227