Driver Distraction Measurement Research Simulator Sickness

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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.