Form 1402 Visual Scanning Training Feedback

OMB Control Number: 2127-XXX

Expiration Date: XX/XX/XXXX

Training Feedback Questions for Visual Scanning Training for Older Drivers

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to 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 (expiration date: MM/DD/YYYY). The average amount of time to complete the form is 10 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.

Statement	For each statement 1-4, circle your level of agreement (1=strongly disagree, to 5 = strongly agree).
1. The training activity I participated in will help me be a safer driver.	1 Strongly Disagree	2	3	4	5 Strongly Agree
2. I would recommend this training activity to a friend or relative.	1 Strongly Disagree	2	3	4	5 Strongly Agree
3. If I started this training activity on my own, outside of any research study, I would have completed all of my training sessions.	1 Strongly Disagree	2	3	4	5 Strongly Agree
4. I would pay for this training.	1 Strongly Disagree	2	3	4	5 Strongly Agree
5. I would pay up to $______ for this training if I received a 10% discount on my car insurance.
6. I would pay up to $______ for this training whether or not I received a discount on my car insurance.

NHTSA Form 1402