Form NHTSA Form Number NHTSA Form Number Research Participant Informed Consent Form

Battelle Institutional Review Board
OMB Control Number: 2127-NEW
Approved to 7 August 2019
Completion time: 30 minutes
Expiration Date: XX/XX/XXXX
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 2127-NEW (expiration date: MM/DD/YYYY). The average amount
of time to complete the survey is 30 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.

Research Participant Informed Consent Form
This informed consent form describes the procedures, what you can expect as a participant, and other important
information that you should consider before volunteering to be in this research study.
Please read this consent form carefully and ask as many questions as you like before deciding if you want to
participate.
Project Title: Battelle Driving Study
Project No.: 100107273
Study Leader/ Principal Investigator: Dr. Christian M. Richard
Phone: (206) 528-3249 Email: [email protected]
Address: Suite 350, 1100 Dexter Ave N. Seattle WA, 98109
Purpose of the Research Study
The objective of the study is to understand how driving education affects the behavior of drivers who recently
received speeding tickets. The findings from this study will be used to develop programs to make American
roads safer. This study is being conducted by Battelle for the National Highway Traffic Safety Administration
(NHTSA). Dunlap and Associates, Inc. will help Battelle collect study data.
Procedures
If you agree to be in our study, we ask you to take part in the following activities:
a. First visit (today)
 Complete the screening questionnaire and qualify for the study
 Voluntarily consent to be in our study and complete the consent form
 Complete a contact information form
 Complete a 25-minute driving questionnaire
 Allow us to put a device in your vehicle to record its speed and location for about 60 days.
 Agree in writing to allow our study team to obtain and review your driving record during the study
and again, approximately one year after the study has ended.
o
There will be no cost to you. We will ask you to fill out NC DOT driver record request and
authorization forms for each request.
 We will pay you $25.00 for your time and effort after today’s visit if you complete all of the items
above
b. Second visit (about 30 days after start)
 Drive your vehicle to the facility located in central Wake County.
 Take a 1 to 2 hour-long driving education course. This will include a brief course-evaluation
questionnaire.
 Let us check that the recording device in your vehicle and conduct any required maintenance on
the device
 We will pay you $75.00 for your time and effort after you complete the items above
NHTSA Form 1493

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Battelle Institutional Review Board
Approved to 7 August 2019
Completion time: 30 minutes
c.

OMB Control Number: 2127-NEW
Expiration Date: XX/XX/XXXX

Final visit (about 60 days after start)
 Drive your vehicle to the facility located in central Wake County
 Complete a 25-minute driving questionnaire
 Allow us to remove the recording device from your vehicle.
 You will be paid $100.00 for your time and effort if you complete all of the items above.

The Wake County Courthouse is helping us recruit possible drivers for our study. This is their only role in the
study. Courthouse personnel will not know if you take part in the study and they will not have access to any
information you share with us.
Risks and Benefits
We believe that the potential risks to you from taking part in our study will be minimal.
The recording device will be mounted in a way that will not interfere with any part of your normal view of the
roadway. The device will not affect the operating or handling characteristics of your vehicle in any way. Except
for your two visits to the study facility, we will not ask you to change your daily driving routines in any way.
The recording device is a “Global Positioning System (GPS)” device that sends signals to orbiting satellites in
order to determine a vehicle’s position and speed. After the recording device is installed in your vehicle, the
device will record your location, the time of day, and travel speed.
GPS data is potentially subject to subpoena by law enforcement officials. In the unlikely event that GPS data is
subpoenaed for any reason, Battelle will have to comply with the subpoena.
You may personally benefit from the information presented in the traffic safety education course. You also will
receive a total of $200 for completion of the entire study.
Privacy and Data Confidentiality
We have taken many steps to assure that your data will be kept confidential and secure:
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All electronic study data will be stored in secured, access-controlled computer servers at Battelle. Only
staff with permission can access the data.
We will separate your name and other information that could be used to identify you from all other the
data you give us. The data you give us includes your questionnaire responses, recording device data,
and driving record.
We will assign a Study ID to the data you give us. The Study ID cannot be used to identify you.
A code-key links your name to your Study ID. Only the research team has the code-key, and it will be
stored in a secure location.
Your name, identifying information, and the “code-key” will be kept for 3 years and then destroyed. After
that, there is no way to associate your identity with your study data. Study data that cannot be
associated with your identity will be kept indefinitely.

After removing your name and all identifying data, we will analyze everyone’s data to develop reports and
recommendations. We call this “de-identified” data. Battelle and NHTSA will have access to the de-identified
data for research purposes.

The recording device
The recording device will collect information about vehicle location, time of day, and travel speed while you drive.
 We will only use the location information to identify what type of road you are traveling on, such as a
residential road or a highway.
 We will not keep any information about addresses, destinations, or specific driving routes.
 We will always delete the first and last 60 seconds of each driving trip so that we do not know your
original starting point and final stopping location.
NHTSA Form 1493
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Battelle Institutional Review Board
OMB Control Number: 2127-NEW
Approved to 7 August 2019
Completion time: 30 minutes
Expiration Date: XX/XX/XXXX
 We will remove the date of each trip and replace it with a number that represents the day in the study.
Your driving records
With your permission, we will receive your driving history data from the State’s Department of Motor Vehicles
during the study, and again in about one year.
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We will remove your identifying information from the driving history data as soon as we receive it.
We will use this data only for research purposes.
Your participation in this study has no impact on your driver record or any other official records at the
State, Federal, or local level.

This study has been reviewed and approved by the Battelle Institutional Review Board (IRB). The IRB assures
that protections for human subject research are reasonable and adequate. It is possible that the Institutional
Review Board (IRB) may view this study’s data for auditing purposes.
Insurance
To take part in this study, you will be required to provide proof of vehicle liability insurance at minimum.
Battelle will not be able to pay you for any expenses, vehicle damage, or injury that may occur while you are
taking part in our study. Battelle will not be able to provide you with any medical treatment or financial
compensation, except as provided through remedies available by law.
In the event of any accident that may damage Battelle’s monitoring equipment, you will not be responsible for
costs of replacement or repair. If the monitoring equipment is stolen or lost, we will ask you to provide a copy of
a Police Report. Without a police report, you will not be eligible for payment for the final visit to the study facility.
Termination of the Research Study
You are free to choose to participate in this research study. If you choose not to participate, you will not be
penalized or lose any benefits to which you are otherwise entitled. You are free to end your participation at any
time without penalty. If you choose to withdraw, please tell us. We will pay you for the tasks that you completed
and remove the recording device.
The Principal Investigator can also end your participation for any reason; including, safety reasons, to maintain
study integrity and validity, and/or if the study ends early.
Available Sources of Information
Dr. Christian Richard, the Principal Investigator, can answer questions you have about this research study. Dr.
Richard can be reached at (206) 528-3254 or [email protected]. If you have questions about your rights as a
human subject, you may contact the Battelle Institutional Review Board, toll-free, at 1-877-810-9530.
Authorization
I have read and understand this consent form. I understand that my participation in this research study is
voluntary. I understand that I will receive a copy of this form. I voluntarily choose to participate. I understand that
my consent does not take away any legal rights in the case of negligence or other legal fault of anyone who is
involved in the study. I understand that nothing in this consent form is intended to preempt any applicable
federal, state, or local laws regarding informed consent.
By signing this form, I understand that I meet the following criteria:
 I am 18 years of age or older
 I have a valid North Carolina driver license
 I drive at least 5,000 miles/year
 I am the sole owner of the vehicle that I will use for this study
 I have vehicle insurance appropriate for the state I reside in
NHTSA Form 1493

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Battelle Institutional Review Board
OMB Control Number: 2127-NEW
Approved to 7 August 2019
Completion time: 30 minutes
Expiration Date: XX/XX/XXXX
 I have received at least one speeding-related citation within 12-month period

Participant:
__________________________________________
Name of Participant (Printed or Typed)
______________________________________________________________________________
Signature of Participant
Date
Time
Researcher Obtaining Consent:
I have discussed this research study, its objective, methods, associated risks, and benefits with the participant
and have fully answered all questions to his / her satisfaction.
___________________________________
Name of Researcher Obtaining Consent (print)
___________________________________
Signature

NHTSA Form 1493

____________
Date

____________ AM/PM
Time (hh:mm)

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