Form NHTSA FORM 1345 NHTSA FORM 1345 Eligibility Questionnaire

OMB Control No. 2127-XXXX

Expiration Date XX/XX/XXXX

This collection of information is voluntary and will be used to screen for eligible participants. Public reporting burden is estimated to average 10 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.

VIRGINIA POLYTECHNIC INSTITUTE AND STATE UNIVERSITY

Eligibility Questionnaire for Participants of Investigative Projects

Note to Researcher:

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 Rd, in Blacksburg, VA. We are currently recruiting people to participate in a research study. This study involves participating in one session lasting approximately two hours during daytime hours.

VTTI is working on a project on the use of Head-Up Displays for the National Highway Traffic Safety Administration. As part of this project, we are asking people to help evaluate some new technology and drive our research vehicle, which is a Buick Lacrosse, on both public roads as well as the Smart Road, which is our closed to the public test track. The vehicle is instrumented with data collection equipment, including video cameras which will record you while you are in the vehicle.

This study has a few parts to it. First, we would ask you to complete some paperwork; then perform a simple vision and hearing test. Second, you will receive an orientation on Head-Up Displays. A Head-Up Display projects an image onto the windshield and it appears about 6.5 feet in front of the driver. The display shows information about the vehicle, such as current speed. You will then be given an orientation of the research vehicle, and you will drive to US-460 and proceed along a predetermined route. Once the public road portion is completed, we will proceed back to VTTI, to our test track, the Smart Rd. An experimenter would be with you at all times. This project pays $70.

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.

1. Do you have a valid U.S. driver’s license?

• Yes If yes, how long have you had a license?____________________

• No

2. What is your current age? _______________(Stop if not 18 years or older)

3. Are you a U.S. Citizen?

• Yes

• No

If not a U.S. Citizen: Do you have a green card?

• Yes

• No

4. Are you willing to provide your Social Security # should you participate, as required by the University? (explain they will be asked to complete a W-9 if they ask why)

• Yes

• No

Please note that for tax recording purposes, the fiscal and accounting services office at Virginia Tech (also known as the Controller’s Office) requires that all participants provide their social security number to receive payment for participation in our studies. Or if a VT employee they may provide their VT employee #.

5. Are you able to drive an automatic transmission vehicle without assistive devices or special equipment?

• Yes

• No

6. How often do you drive per week (on average)? How many days/week? ______________

7. Have you ever been in a driving study or any experiments at the Virginia Tech Transportation Institute? If "yes," please briefly describe the study.

• Yes ______________________________________________________

• No (Cannot have been in a type of surprise study)

8. Have you had any moving violations in the past 3 years? If so, please explain.

• Yes ______________________________________________________

• No

9. Have you been involved in any auto accidents in the past 3 years? If so, please explain.

• Yes ______________________________________________________

• No

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

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

1. Neck or back pain or injury to these areas

   • Yes

   • No

2. Head injury, stroke, or illness or disease affecting the brain

   • Yes

   • No

3. Heart condition (cannot be current heart condition, which limits their activity)

   • Yes

   • No

4. Current respiratory disorder or condition which requires oxygen

   • Yes

   • No

5. Epileptic seizures or lapses of consciousness within the past 12 months

   • Yes

   • No

6. Chronic migraines or tension headaches (more than 1/mo during the past year)

   • Yes

   • No

7. Motion Sickness, inner ear problems, dizziness, vertigo, or any balance problems (current)

   • Yes

   • No

8. 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)

   • Yes

   • No

9. Have you had major surgery in the past 6 months?

   • Yes

   • No

10. Advanced osteoporosis (softening or weakness of the bones)?

    • Yes

    • No

11. A

    
    

    re you taking any substances on a regular basis which could impair your motor skills or your ability to drive?

    • Yes

    • No

11. (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

12. Do you have normal, or corrected to normal, hearing and vision? If no, please explain.

• Yes

• No ______________________________________________________

13. For this study, you will be asked to drive without sunglasses. Will this present a problem should you be eligible to participate?

• Yes

• No

Do you wear eyeglasses that tint or darken in the sunlight (while seated in a vehicle)?

• Yes __________

• No ___________

14. Are you comfortable reading, writing, and speaking English?

• Yes

• No

15. Are you currently employed in the design, engineering, or development of automotive-related technologies?

• Yes

• No

If not Eligible: Would you like to be contacted for future studies? Yes: ______ No: _______

Please send Database Information Letter: Name: ___________________________

E-mail or mailing address: ____________________________ YOB:___________________

If Eligible:

Name: ___________________________

We encourage you to read a copy of the Information Sheet prior to coming in for your scheduled appointment. You may review it ahead of time; contact us with any questions or concerns. You will be asked to sign this document upon arrival at VTTI prior to participating.

E-mail or mailing address: _____________________________________________________

Availability: _____________________________________________

Scheduled on (date & time):________________________________________________

Town or city: __________________ approximate travel time to VTTI: ___________

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

• Provide a copy of the Information Sheet to the participant if desired by email, fax, in-person pickup at VTTI, or by phone. If phone is selected, and if there is sufficient time before the participant arrives for their scheduled appointment, the Information Sheet will also be mailed to them.

Criteria For Participation

1. Must hold and be able to present a valid U.S. driver’s license at time of participation and must be an experienced driver (at least 2 years).

2. Must be 18 years old or older.

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

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

5. Must be able to drive an automatic transmission without special equipment.

6. Must currently drive at least 3 times a week.

7. Must not have participated in a similar study (one using a surprise event or deception).

8. Must not have more than two driving violations in the past 3 years.

9. Must not have caused an injurious accident in the past three years.

10. Health Questions:

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

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

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

    4. Cannot have current uncontrolled respiratory disorders or disorders requiring oxygen

    5. Cannot have had epileptic seizures or lapses of consciousness within the last 12 months

    6. Cannot have chronic migraines or tension headaches (no more than one per month during the past 12 months).

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

    8. 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)

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

    10. Cannot have advanced osteoporosis (softening or weakening of the bones)

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

11. If pregnant, encourage them to speak with their doctor first.

12. Must have normal (or corrected-to-normal) hearing and vision.

13. Must be able to drive without sunglasses or lenses that darken in the sunlight.

14. Must be able to read, write and speak English well.

15. Must not be involved/employed in the design, engineering, or development of automotive-related technologies.