Form NHTSA Form 1311 NHTSA Form 1311 Simulator Sickness Questionnaire

OMB Control No. 2127-XXXX

Expiration Date XX/XX/XXXX

Question Set 3: Simulator Sickness Questionnaire

This collection of information is voluntary and will be used to determine if you are well enough to continue performing the study protocol and, upon completion of the protocol, whether you are well enough to safely depart the study site in your personal vehicle. Public reporting burden is estimated to average 2 minutes per response, including the time for reviewing instructions and completing the collection of information.

Any data collected relating to this study that personally identifies you or that could be used to personally identify you will be treated with confidentiality. Contact information data will be stored on password-protected directories and destroyed after the study is complete, unless you have indicated that you have interest in participating in future NHTSA studies in which case we will retain your name, contact information, and the data provided by you in connection with screening process (except specific health information) by which you were selected to participate in this study. NHTSA will not release any information collected regarding your health and driving record.

Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 2127-XXXX. 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.

Participant Number: _____________

Instructions: Circle one option for each symptom to indicate whether that symptom applies to you right now.

1. General Discomfort None Slight Moderate Severe

2. Fatigue None Slight Moderate Severe

3. Headache None Slight Moderate Severe

4. Eye Strain None Slight Moderate Severe

5. Difficulty Focusing None Slight Moderate Severe

6. Salivation Increased None Slight Moderate Severe

7. Sweating None Slight Moderate Severe

8. Nausea None Slight Moderate Severe

9. Difficulty Concentrating None Slight Moderate Severe

10. “Fullness of the Head” None Slight Moderate Severe

11. Blurred Vision None Slight Moderate Severe

12. Dizziness with Eyes Open None Slight Moderate Severe

13. Dizziness with Eyes Closed None Slight Moderate Severe

14. *Vertigo None Slight Moderate Severe

15. **Stomach Awareness None Slight Moderate Severe

16. Burping No Yes If yes, no. of times ______

17. Vomiting No Yes If yes, no. of times ______

18. Other ____________________________________

* Vertigo is experienced as loss of orientation with respect to vertical upright.

** Stomach awareness is usually used to indicate a feeling of discomfort which is just short of nausea.

NHTSA Form 1311