5900-305 Surveillance Screening Tool

MY Make Model Test Group Control # -______

Page 16 of 8

TELEPHONE SCREENING TOOL OMB No. 2060-0086

For Surveillance Class Expires (###)

VEHICLE CONTROL NUMBER DATE

ADMINISTERED BY

OWNER'S NAME

STREET ADDRESS

CITY STATE ZIP

(CALL NUMBER BELOW THAT IS MARKED WITH AN "X")

TELEPHONE (Home) / / (Business) / /

BEST TIME TO CALL

Privacy Act Statement

Title 42, United States Code, Section 7451, Compliance by vehicles and engines in actual use, authorizes the collection of this information. The primary use is to provide an instrument by which individuals may indicate interest in and eligibility for participating in EPA’s Light-Duty In-Use Testing Program. Additional disclosures of this information may be made pursuant to published routine uses, including to appropriate agencies for law enforcement purposes and to contractors working for EPA who have a need to know in the course of that work.

Providing the requested information is voluntary, but failing to do so will result in EPA’s inability to approve your participation in the Light-Duty In-Use Testing Program.

DATE OF CONTACT _______________________ TIME OF CONTACT __________________

INDIVIDUAL CONTACTED_______________________________________________________

TO BE COMPLETED ___________________ DATE AND TIME OF COMPLETION___________

Public reporting burden for this collection of information is estimated to vary from 1 to 60 minutes per response, with an average of 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Chief, Information Policy Branch, PM‑223, U.S. Environmental Protection Agency,40l M St., S.W. Washington, DC. 20460; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC. 20503.

You have been selected from a list of vehicle owners living in the Detroit/Ann Arbor metropolitan area to participate in a study of vehicle emissions being conducted by the U.S. Environmental Protection Agency. Vehicle recruiting is done by Jacobs, a contractor to the U.S. Environmental Protection Agency. Your participation in this program is strictly voluntary. Testing may take approximately 2 to 4 weeks, occasionally longer. Maintenance may be performed on your vehicle depending upon program requirements.

You will be given a list of any parts that are replaced.

You can choose to bring your vehicle to the EPA facility or we can pick it up at your convenience from your home or workplace during normal business hours.

The following are incentives for participating in our program:

You will be offered $20.00 per day and a loaner vehicle for every day your vehicle is at the National Vehicle and Fuels Emission Laboratory (NVFEL). If you do not want a loaner vehicle, you will be offered $50.00 per day. The compensation will be based on whole days, beginning with the day your vehicle arrives. It will end one day after you are notified your car is ready for return. If you bring your vehicle to the EPA and it is rejected, you will receive a $20 payment before you leave.

If your incentive is $600 or more we are required to ask for your Social Security Number for tax purposes. If you do not wish to provide your social security number, you have the option to cap the total incentive at $599.

Are you willing to provide your Social Security Number if your incentive is $600 or more? YES NO

If NO, would you like the option to cap your incentive at $599? YES NO

Are you willing to participate? YES NO

If you are not, may we ask why not? ______________________________________________

IF “NO” ELIMINATE THIS VEHICLE. THIS PERSON CANNOT PARTICIPATE IN THE PROGRAM.

SENTENCES IN CAPITAL LETTERS ARE INSTRUCTIONS TO THE CLERK

AND ARE NOT INTENDED TO BE READ TO THE OWNER

IF RESPONSE IS POSITIVE:

For the purpose of this study, I am going to ask you some questions about your vehicle's maintenance and usage history. Please have your maintenance records in front of you for reference during the following questions. You should answer these questions to the best of your knowledge and indicate when you are not sure of something.

1. a. What is the test group of your vehicle? The engine family can be found on a Vehicle Emission Control Information decal located underside of the hood.

/ / Owner is unable to locate.

/ / Owner located. TG# ____________________________

/ / Test group located when vehicle arrived at the Lab.

TEST GROUP

Engine Family must be =

b. What is the vehicle identification number?

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

c. What is the model of your vehicle? ____________________

d. What kind of transmission does your vehicle have? AUTOMATIC MANUAL OTHER

If other, describe:_________________________________________________________

e. Is your vehicle air conditioned? YES NO

f. What mileage is indicated on your odometer? ____________________

Has the odometer ever not functioned properly? YES NO

If yes, approximately how long (months/miles) was it inoperable? ________________

CONSULT EPA STAFF FOR ELIGIBILITY IF THE RESPONSE IS "YES" to f.

2. Has your vehicle’s catalyst ever been replaced or removed?

YES / / NO / /

IF “YES” CALL EPA STAFF FOR ELIGIBILITY.

3. a) Have you kept records of the maintenance and repairs performed on your vehicle?

YES / / NO / /

b) To prepare for testing, the glove box and trunk will need to be opened by Jacobs and EPA personnel. Frequently, records pertaining to the vehicle's maintenance history are found in the vehicle. Will you allow all records (those provided by you and those found) to be reviewed and duplicated?

YES / / NO / /

4. a, EPA may need to share the VIN, maintenance records and answers to this questionnaire with the manufacturer so that the vehicle is correctly tested and the results understood. Do you agree to this?

YES / / NO / /

b. Occasionally the manufacturer wants to test the vehicle. If the manufacturer requests your contact information may we share it with the manufacturer?

YES / / NO / /

IF RECORDS ARE AVAILABLE, INFORM OWNER THAT: It is important that they are brought to the lab for review and duplication.

5. Have you ever used any fuel other than that recommended by the manufacturer in your vehicle (eg. super unleaded, diesel, gasahol) ? YES / / NO / /

If Yes, what have you used? ___________________________________________________________

How often have you used it? ___________________________________________________________

When was the last time you used it?______________________________________________________

6. Has your vehicle:

a) Been in an accident? YES / / NO / /

b) Had any engine repairs? YES / / NO / /

c) Any vehicle modifications to the interior or exterior? YES / / NO / /

If “yes” to any of the above, please describe: ____________________________________________________________________________________________________________________________________________________________________________

Has your vehicle had any:

DATE:

d) Body work? YES / / NO / / ________________

e) Glass repair or replacement? YES / / NO / / ________________

f) Paintwork or detailing? YES / / NO / / ________________

g) Rustproofing or undercoating? YES / / NO / / ________________

h) Other? YES / / NO / / _________________

If “yes” to a – h above, please describe: ____________________________________________________________________________________________________________________________________________________________________________

i) New tires? YES / / NO / /

Date and mileage of the most recent tire installed? Date_________ Mileage___________

j) Any Tire repairs? YES / / NO / /

Date and mileage of the most recent tire repair? Date__________ Mileage____________

IF “YES” TO ANY a) THROUGH j) ABOVE AND DATE IS LESS THAN 6 MONTHS FROM THE TIME OF THIS QUESTIONNAIRE, AND/OR 6,000 MILES SINCE A TIRE REPLACEMENT, consult with EPA staff before accepting this vehicle. If “NO” TO ALL, GO TO 7

If a replacement part was installed, was it an original manufacturer part? YES / / NO / /

What was the approximate cost of the work done?

Do you have any documentation of the work that was done?

7. Is your vehicle equipped with a trailer hitch? Yes ____ No ____

Was the hitch installed by: dealer other

How much total weight has been hauled?

trailer + cargo = _____________________________________________

IF YES, CONSULT WITH EPA STAFF BEFORE ACCEPTING THIS VEHICLE.

8. Other information needed for this class.

_______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

INFORM THE OWNER THAT:

1. All valuables should be removed from the vehicle (including those in the glove box) prior to bringing the vehicle to the lab.

Information Update Page

1. Has any maintenance been performed on your vehicle since the time the telephone questionnaire was administered? (i.e., oil change, filters changed, spark plug change, any adjustments, etc.) Y N

If "YES", please complete the following:

What was done?

When was it done?

What was the odometer reading?

Where was it done?

2. Has any other significant incident occurred since the questionnaire was administered? (i.e., accident, operational problems, pulled trailer, vehicle rust proofed, etc.) Y N

If "YES", please complete the following:

What happened?

When did it happen (include odometer reading)?

How does it affect the vehicle now?

_______________________________________________ _____________________

Participant Signature Date Jacob’s Representative

VIN________________________________

State of ________________________________County of_____________________________

I, _________________________________________________________________________,

being first duly sworn, depose and say:

I am the owner ( ) and/or joint owner ( ) and/or principal driver ( ) of the vehicle

described in this questionnaire and have personal knowledge of all matters discussed herein.

I have read the responses to the questions stated above, and such responses are true and accurate

to the best of my knowledge and belief.

_______________________________________

(Signature)

___________________________

(Date)

Subscribed and affirmed before me, a Notary Public, and I hereby certify that I am duly

authorized by the laws of the State of Michigan, County of Washtenaw, to administer oaths.

__________________________________

Notary Public

__________________________________ (Seal)

(Date)

My commission expires: _________________

(Date)

EPA Form 5900-305

(Revision Date 12-9-2013)