Form NHTSA Form 1282 NHTSA Form 1282 Eligibility Questionnaire

OMB Control No. 2127-XXXX

Expiration Date xx/xx/xxxx

Eligibility 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 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

Eligibility Determination Questionnaire

Hi. Thanks for calling.

Purpose:

We are conducting a study investigating drivers’ natural driving behavior on real roads.

Activities:

You will drive one research vehicle equipped with advanced technologies for a total of three weeks. During the three weeks, we would like you to use the research vehicles in place of your personal vehicle. While you drive, a computer located in the trunk will continuously collect data about how and where you drive. Some examples of these types of data collected are your speed and location. Additionally, you will be video and audio recorded while you drive. You can take the vehicle anywhere within the continental US. However, we ask that you don’t take the car into Canada or Mexico because we believe that you will have a difficult time getting it back into the country due to the specialized equipment that is on board. If you qualify for the study, you will need to come to Ann Arbor to pick up a car. We will schedule two return visits with you to bring the vehicle back to UMTRI for data downloading and vehicle maintenance. This is an important requirement for participation to make sure the study goes smoothly. The two return visits will be exactly at the end of each week. During your return visits, we will fill up your gas tank for free. You will also be receiving training during your first return visit. This training session lasts about 30 minutes. This training session will help you to get familiar with the vehicle control and advanced in-vehicle technologies.

Compensation:

For your participation in the study, in addition to the use of a car and two free full tanks of gas, you will receive $90.

Overview:

In order to determine your eligibility, I have to ask you some questions regarding your driving experience, age, whether you have a valid driver’s license, etc. This should take about ten minutes. Are you interested in proceeding with the questionnaire?

1. What is your age?

2. Gender: male or female?

3. Do you have a valid U.S. driver’s license with your photo on it? Are there any restrictions on your driver’s license? If you qualify, you will need to bring your driver’s license with you to the study session.

(Exclude if they do not have, or cannot produce, a valid, unrestricted [typically issued at age 18 - provides unlimited driving privileges 
to teenagers who have progressed through the graduated system and have an established history of safe driving], driver’s license with their photo.)

4. How many years have you been driving?

(Exclude if less than one year)

5. How many miles did you drive last year? How many trips did you drive per week on average and how long is each trip on average?

(Exclude if less than 25% below the mean for their age/gender group or if drive less than 5 trips per week. Source: NPTS)

6. What type of car do you drive (make, model, model year)? _________________

Are there any advanced safety systems in your car? Yes/No.

7. How often do you wear your seat belt while driving?

1. All the time; b) Most of the time ; c) Sometimes ; d) only occasionally ; e) Never

7a. Has there been ANY time in the past year that you did not wear your seatbelt when you were driving?

1 Yes

2 No

3 don’t know

4 refused

7b. Of all the trips that you made last month, how often did you wear your seat belt?? >90% , or <80%?

7c. Which of the following best describes how often you wear your seatbelt when you’re a driver? (Exclude if they answer always)

1 Always (>90%)

2 Most of the time (60%~80%)

3 Some of the time (30%~50%)

4 Never (<10%)

7d. Which of the following best describes how often you wear your seatbelt when you’re a front-seat passenger?

1 Always (>90%)

2 Most of the time (60%~80%)

3 Some of the time (30%~50%)

4 Never (<10%)

8. Under the following circumstances, when would you choose not to put on your seat belt? (choose all applicable ones)? (Exclude if they answer Never)

1. Driving within a few miles of your home;

2. Only driving on local roads;

3. Driving out very early in the morning/ very late at night when there is no surrounding traffic ;

4. Driving with your friends;

5. Traveling alone;

6. When police are likely to not be present;

7. Never;

8. Other___

9. (a) What kind of active safety systems are available in your current vehicle?

Forward crash warning; Lane departure warning; Adaptive Cruise Control; Blind spot detection; None

(b) Which safety system do you like the best?

(c) Which vehicle feature do you value the most (pick one)

Safety; Comfort; Cost(cheap or expensive); Size (compact or big);

10. Do you or any members of your household work in any of the following fields or for these types of companies: (If yes to any, thanks and end)

• Design, engineering, or development of automotive-related technologies?

• News or media company

• An auto manufacturer

• A manufacturer, distributor or retailer of automotive parts

• An auto mechanic / technician / auto repair shop

• A professional driver

11. Have you been convicted of any of moving violations in the past 24 months?

We would like to review your driving record to determine your eligibility to participate. If you agree to allow UMTRI to review your driving record, the information will be kept strictly confidential to the extent permitted by law and will not be shared with anyone outside of the UMTRI research team. Later, should you choose to participate in our study, we will ask for your driver’s license number to be able to review your driving record. Again, your response is voluntary. You may refuse, and UMTRI will not keep any record of your response.”

Does the University of Michigan Transportation Research Institute have your permission to request your driving record from the State of Michigan and review it to confirm your eligibility to participate?

(Exclude if permission to access their driving record is denied.)

9. Are you able to drive a car equipped with an automatic transmission without assistive devices or special equipment (for example, pedal extension, hand controls etc.)?

(Exclude if they answer no)

10. Do you use any corrective devices to hear or to see? If you qualify, you will need to bring your hearing aid or glasses with you to the study session.

(Exclude if they acknowledge the need for, but fail to use, corrective devices)

11. Are you currently taking any medicine which may impair your ability to drive? If yes, please explain.

(Exclude if answer is yes)

Are you interested in participating? Do you have any questions about the study or your participation? I will need your driver license number to review your driving record. If you are qualify for the study, I will send you a packet of materials for you to review prior to coming to pick up a car. The packet will include an informed consent form and several questionnaires that you will need to complete.

Name ________________________________________

Address ______________________________________

______________________________________

Driver’s License # ______________________________________

Home Ph: ­­­­­__________________________ Work Ph: ­­­­­__________________________

Cell Ph: ­­­­­__________________________

NHTSA Form 1282