OMB#: 2127-xxxx
Expiration Date: xx/xx/xxxx
Older Drivers’ Self-Regulation and Exposure
Appendix D
(Oral interview to be conducted by researcher)
Paperwork Reduction Act Burden Statement: Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to, 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 xxxx-xxxx. The average amount of time to complete this survey is 5 minutes. All responses to this collection of information are voluntary. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590
Will you be spending the next 60 days in this area and be available to participate in this study?
Yes No (Stop, they are not eligible for the study)
What is your date of birth? _______________________________________________
Do you have a valid driver’s license, and if so, when does it expire?
Yes No (Stop, they are not eligible for the study)
Expiration date: _______________________________________________
Do you have any restrictions on your driver’s license?
Yes No
If yes, what are they (List all): _______________________________________________
Do you use adaptive controls in your car?
Yes (Stop, they are not eligible for the study) No
About how many times per typical week do you drive? ___________
(Must be at least 3 to qualify)
Do you drive one particular vehicle for 90% or more of these trips?
Yes No (Stop, you are not eligible for the study)
Do you have to get anyone’s approval or permission each time you want to use that vehicle?
Yes No
If yes, who?_______________ (Stop, you are not eligible for the study)
Is this vehicle available to use as your primary vehicle for at least the next 30 days as part of this study?
Yes No (Stop, you are not eligible for the study)
Who owns the vehicle?
Yourself Your spouse Jointly owned by respondent and someone else Other family member Other______________________________________
Which statement best describes who drives this vehicle?
I’m essentially the only driver
I do the majority of its driving
I share it about equally with someone else
Someone else does the majority of its driving
Do you drive the majority of trips for your household?
Yes No
Are there any types of roadways, traffic situations, or weather conditions you try not to drive in?
Yes
No
If yes, what are they? (Do not prompt with these answer categories)
Alone
Bad weather (e.g., rain, snow)
Night in bad weather
Rush hour
Unfamiliar areas
Interstates/limited access highways
High speed roads
Night
High traffic roads
Long distances
Other _________________________________________________
NHTSA Form 1295
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | kathy.sifrit |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |