NHTSA Form 1263 Eligibility Questionnaire

O MB Control No. 2127-NEW NHTSA Form 1263

Expiration Date xx-xx-xxxx

DRAFT 12 March 2015

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-NEW. Public reporting for the eligibility questions of this collection of information is estimated to be approximately 3 minutes per response, including the time for reviewing instructions, completing and reviewing the eligibility questions of this 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 Avenue SE, Washington, DC, 20590.

Under the sponsorship of the National Highway Traffic Safety Administration (NHTSA), the Volpe Center is currently conducting driving simulation studies of how drivers react to different kinds of electronic gear selection controls. The studies involve answering a brief series of questions about your driving history and driving a vehicle simulator fitted with one of several different types of gear selectors. After about 10 minutes of routine simulated driving, you may be presented with more challenging driving tasks. While you drive, a number of different measurements will be collected. These measures may include, but are not limited to, pedal and gear-selector usage, steering wheel control, video recordings of your head, eye, foot, and hand movements, and audio recordings.

The Volpe Center is located at 55 Broadway in Cambridge, MA 02142 near the Kendall Square station on the MBTA Red Line. Free parking is available. See map at: http://www.volpe.dot.gov/about-us/contact-us.

The study lasts approximately 1 hour 30 minutes. You will be compensated $75 for your time participating in the study and traveling to/from the Volpe Center.

Would you be interested in participating in this study? (YES / NO)

If you answered YES, please answer the following questions. If you feel uncomfortable with any question, feel free not to answer it.

1.	Are you Male or Female?		Male	Female
2.	What is your year of birth?		__ __ __ __ Y Y Y Y
3.	Do you currently have a valid driver’s license?		Yes	No
4.	How many years have you been driving?
5.	On average, how many days a week do you drive a car? (Please enter a number from 0 to 7.)
6.	Please enter the make/model/year of the car you currently drive most frequently
7.	Are you fully comfortable speaking and reading English?		Yes	No
8.	Have you driven a vehicle with any of the following types of gear selectors? Check all that apply. Conventional console shifter Gated console shifter Simple joystick Multifunction joystick Push button Rotary knob Paddle Shifters mounted on the steering wheel Manual Transmission (stick-shift)	Never	A Few Times		Regularly

The following contact information is requested for the purposes of scheduling a study appointment:

Name: _________________________________________________

Email address: _______________________________________

Preferred telephone: ________________________________

Days and times that would be convenient for you:

NOTE: The formatting of this form may be adapted for email, on-line use, and other recruitment methods.

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