Form NHTSA FORM 1346 NHTSA FORM 1346 Demographic Questionnaire

Participant #:_____

OMB Control No. 2127-XXXX

Expiration Date XX/XX/XXXX

VIRGINIA POLYTECHNIC INSTITUTE AND STATE UNIVERSITY

Demographic Questionnaire for Participants of Investigative Projects

This collection of information is voluntary and will be used to screen for eligible participants. Public reporting burden is estimated to average 3 minutes, 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.

General Information:

Date:
Gender:
Age:

1. Are you left or right handed? Left______Right___________

2. Are you left or right eye dominant (result of test)? Left______Right___________

3. Do you have normal color vision (result of test) Yes______No___________

Driving History:

1. At what age did you receive your driver’s license?

__________

2. Please estimate the following:

1. Hours driven per week: ___________________________

2. Miles driven per week: ___________________________

NHTSA Form 1346