Form NHTSA Form 1337 NHTSA Form 1337 Participant Screening

OMB#: 2127-xxxx

Expiration Date: xx/xx/xxxx

Screening #: ________________ Screener _____________ Screening Date _________________

Osprey Screening Questionnaire (HV-CWI)

This collection of information is voluntary and will be used to screen for eligible participants. Public reporting burden is estimated to average 10 minutes per person, including the time for reviewing instructions searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Information will be kept confidential, and your name will not be attached to any data. 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.

Note:

Initial contact between participants and researchers may take place over the phone. If this is the case, read the following Introductory Statement, followed by the questionnaire. Regardless of how contact is made, this questionnaire must be administered verbally before a decision is made regarding suitability for this study.

Introductory Statement:

After prospective participant calls or you call them, use the following script as a guideline in the screening interview.

Hello. My name is _____ and I'm with the Virginia Tech Transportation Institute, here at the Smart Road, in Blacksburg, VA. VTTI is working on a project for the National Highway Traffic Safety Administration. As part of this project, we are asking qualified commercial motor vehicle drivers like you to drive our tractor trailer on our test track and to evaluate some new in-vehicle technologies. This research involves participating in one session lasting approximately 2 hours. Some participants will be scheduled during nighttime hours (must be dark) and some during the daytime hours, but not both. An experimenter will be in the truck with you at all times.

Once you arrive for your appointment, we will first ask you to complete paperwork and a simple vision and hearing test. That will be followed by an orientation of the truck and its controls. Once you are comfortable with the vehicle, you will be asked to proceed with some driving scenarios on our test track. The research vehicle is instrumented with data collection equipment, including video cameras which will record you while you drive. All information we collect during this process will be held in strict confidence. The compensation for participating in this study will be $40/hr. We also cover any travel time for anything over 30 minutes away from our location in Blacksburg, VA. The compensation for travel time will also be at a rate of $40/hr. (Note: there is a limit--up to 3 hours away and does pay for round trip travel time for a max compensation of 6 hours of travel time)

Any questions yet?

(Note, if asked: The research vehicle is a 2007 Freightliner Cascadia with Eaton-Fuller 10-speed transmission and will be pulling an empty 53’ van trailer)

If you are interested in possibly participating, I need to go over some screening questions to see if you meet all the eligibility requirements of this study. Any information given to us will be kept secure and confidential.

Do I have your consent to ask the screening questions? [If yes, continue with the questions. If no, then thank him/her for their time and end the phone call.]

Participant Eligibility Questions:

1. Do you currently hold, a valid U.S. commercial driver’s license, or CDL, which you can present at the time of the study?

YES _____ NO _____ If yes, Class A____ or Class B______

Criterion: they are ineligible to participate if unable to present a VALID U.S. CDL driver’s license. Must be a current Class A.

NOTE: They will be reminded they must present a driver’s license at their appointment if scheduled.

2. On Average how many days a week do you drive a commercial truck? ______________

Criterion: Must drive a tractor-trailer at some point during the past 6 months.

3. What endorsements and restrictions do you hold on your CDL? ________________________

Criterion: Cannot have either restriction:

1. Airbrakes restriction (L or Z) or 2. Automatic Transmission only (E)

4. Do you have a valid Medical Examiner’s Certificate? YES _____ NO _____

Criterion: Must have a valid Medical Examiner’s Certificate

5. Have you primarily driven a manual transmission or an automatic transmission at your place of employment? ___________________________

Criterion: Must be able to drive a manual transmission (10-speed transmission)

6. Are you able to pass a basic color vision test? YES _____ NO _____

Criterion: Must be able to pass a basic color vision test

7. What is your current age? _______________ YOB_________

Criterion: Must be 21 years old or more to participate.

8. Are you a U.S. Citizen or permanent resident with a valid green card?

YES _____NO _____

**Note: participant will need to bring their SS # (the card is not needed if they have their ss# memorized) and green card (if any) to the study for W-9 paperwork for payment.

Must be a U.S. citizen or permanent resident (green card holder).

9. If selected to participate in this study, will you provide your SSN or VT ID number, at the time of participation? (for payment documentation and tax recording purposes Va Tech will require them to complete a W-9)

YES _____ NO _____

Must be willing to provide SSN or VT ID number for payment purposes.

10. Have you participated in a driving study at VTTI before? YES _____ NO _____

If yes, describe the study: __________________________________________________________________________

DO NOT MENTION any of these terms to the caller!!

Criterion: Ineligible if in a previous study involving braking activations, brake lights ahead of them, hard brake event, etc. Cannot have been in the HV-CWI or Glass study.

11. Have you been involved in a DOT-reportable collision in the last year?

YES _____ NO _____

If Yes, they are not eligible to participate.

We need to ask a few questions about your medical history…

Do you have a history of any of the following medical conditions? If yes, please explain.

12. Any history of neck or back conditions, or injury to those areas, which still limit your ability to participate in certain activities?

YES _____ NO _____

If yes, please explain:______________________________________________________________

Cannot have a history of neck or back conditions which still limit their ability to participate in certain activities.

13. Any Head Injury, Stroke, or illness or disease affecting the Brain?

YES _____ NO _____

If yes, please explain:______________________________________________________________

Cannot have a history of brain damage from stroke, tumor, head injury, recent concussion, or disease or infection of the brain.

14. Current heart condition which limits your ability to participate in certain activities?

YES _____ NO _____

If yes, please explain:______________________________________________________________

Cannot have a current heart condition which limits their ability to participate in certain activities.

15. Current respiratory disorder/disease or any condition which requires oxygen?

YES _____ NO _____ Notes:_______________________________________________________

Cannot have current respiratory disorder/disease or disorder/disease requiring oxygen.

16. Any epileptic seizures or lapses of consciousness within the past twelve months?

YES _____ NO _____ Notes:_______________________________________________________

Cannot have had an epileptic seizure or lapse of consciousness within the past 12 months.

17. Chronic migraines or tension headaches? YES _____ NO _____

If yes, more than once a month on average? YES _____ NO _____

Notes:

Cannot have, on average, more than one migraine or severe headache per month during the past yr.

18. Current problems with motion sickness, inner ear problems, dizziness, vertigo, or balance problems? YES _____ NO _____

Cannot have current problems with motion sickness, inner ear problems, dizziness, vertigo, or balance problems.

19. Do you have diabetes which requires insulin? YES _____ NO _____

If yes, please explain:______________________________________________________________

Cannot have uncontrolled diabetes (have they been recently diagnosed or have they been hospitalized for this condition, or any changes in their insulin prescription during the past 3 months)

20. Have you had any major surgery within the past six months, including any eye procedures?

YES _____ NO _____

Must not have had any major surgery within the past 6 months (including eye procedures).

21. Are you currently taking any medicines or substances that may cause drowsiness or impair your driving ability?

YES _____ NO _____

Cannot currently be taking any substances that may interfere with driving ability (cause drowsiness or impair motor abilities)

22. (Females only) Are you currently pregnant? (if “yes,” politely inform the participant: while being pregnant does not disqualify you from participating in this study, you are encouraged to talk to your physician about your participation to make sure that you both feel it is safe.  If you like, we can send you a copy of the consent form to discuss with your physician. Answer any questions)

YES _____ NO _____

(Can still participate, but encourage them to speak with their doctor first)

23. Do you have normal, or corrected to normal, vision in both eyes?

YES _____ NO _____

Must have normal or corrected to normal vision in both eyes. Must pass the vision tests administered at VTTI.

24. Are you available to participate in a 2 hour session during nighttime hours (must be dark)?

YES _____ NO _____

Are you available to participate in a 2 hour session during daylight hours? YES _____ NO _____

Preference, if any: ___________________________________________________

Must be available for either a nighttime session (after dark) or a daytime session (during daytime).

Note: appointments may be avail Mon – Sun (possibly 7 days/week)

25. If scheduled for a daytime session, you will be asked to drive without sunglasses. Will this present a problem should you be eligible to participate?

1. Yes _______

2. No ______

Do you wear eyeglasses that tint or darken in the sunlight while sitting inside a vehicle?

1. Yes _______

2. No _______

Criterion: Must be able to drive without sunglasses or w/o lenses that darken while inside a vehicle

26. Do you have normal, or corrected to normal, hearing?

YES _____ NO _____

Criterion: Must be able to hear and follow researcher’s verbal directions while driving.

Must have normal or corrected to normal hearing. Must pass the hearing test administered at VTTI.

How did you hear about this project? _______________________________________________

Recruiting Others:

Do you know anyone else with a commercial license that may be interested in hearing about this study?

If yes, may we send you the information so you can forward it to them? (Or they can provide our phone #, email, website address to others; we will be happy to speak to anyone interested in hearing more)

Do you prefer we send you the info by Text___________________ Email: ________________________ USPS mail (address):____________________________________________________________________

If Eligible:

Scheduled on (date & time):________________________________________________

Name: ___________________________

Home Phone #: ______________________ Cell#________________ Work #______________

Would they like informed consent form sent to them: Yes: ______No: ______

E-mail or mailing address: _____________________________________________________

Availability: _______________________________________________________________

Town or city & approximate travel time to VTTI: _________________________________

Would you like to be contacted for future studies? Yes: ______No: ______

If yes, collect the following:

Y.O.B. _______________________ Town or city: ________________________ State: _____

Specialty Driver’s License_______________________________________________

if CDL, endorsements/restrictions________________________________________

Make and Model of Primary Vehicle (light) _______________________________________

If not eligible:

Would you like to be contacted for future studies? Yes: ______No: ______

Name: ___________________________ Y.O.B. _______________________

Home Phone #: ______________________ Cell#________________ Work #______________

Town or city: _____________________ State: _____

Specialty Driver’s License_______________________________________________

if CDL, endorsements/restrictions________________________________________

Make and Model of Primary Vehicle (light) _______________________________________

6

NHTSA Form 1337