Form 1492 Participant Screener

Completion time: 8 minutes OMB Control Number: 2127-NEW

Expiration Date: XX/XX/XXXX

Study ID: _________

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 8 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.

Participant Screening Questions

1. If you qualify and complete all study activities, you will receive three separate payments as you complete the following study tasks:

1. You will receive $25.00 (in cash) today if you do all of the following

• Complete the screening questionnaire and qualify for the study

• Voluntarily consent to take part in our study and complete the consent form

• Complete a contact information form

• Complete a 25-minute highway safety questionnaire

• Allow researchers to place a device in your car that will monitor your driving habits (no changes or damage to the car) for 30 days

• Agree to allow our study team to obtain and review your driving record during the study

• Agree to allow our study team to obtain and review your driving record approximately one year after the study has ended.

2. You will receive $75.00 (in cash) approximately 30 days from now if you do all of the following

• Take a 1 to 2 hour education course at a location in central Wake County

• Complete a 25-minute highway safety questionnaire

• Agree to drive for another 30 days with the monitoring device in your car.

3. You will receive $100.00 (in cash) approximately 60 days from now if you do all of the following

• Return the monitoring device after the 60 day study period is completed.

• Complete a 25-minute highway safety questionnaire

Do you wish to continue to the screening questionnaire to see if you qualify for the study?  Yes  No

2. Do you live in Wake County, NC?  Yes  No

3. Do you live in a rural, suburban, or urban area?

    Rural  Suburban  Urban  Other, specify _______________________  Don’t Know

4. On what date did you receive your most recent speeding citation? ______________

5. How many speeding citations have you received in the past 5 years? ________________

6. Have you completed a traffic safety/driver education course in the past 3 years?  Yes  No

If Yes, was this course required by a court?  Yes  No

7. Do you currently have a valid (i.e., not expired or suspended) NC driver’s license?  Yes  No

If yes, do you have any of the following restrictions on your license? (Check all that apply)

 Corrective lenses

 Hearing aids

 Daytime only

 Limited distance from home

 No interstate/highway

 Adaptive (hand) controls (e.g. hand accelerator, brake controls)

 Alcohol interlock

 Other: ____________________________(please specify)

8. What vehicle do you drive most often?

Year: _____________ Make: ____________ Model: ____________  I do not regularly drive a vehicle

1. Who owns the vehicle?

 Self  Self and co-owner (joint ownership)  Spouse/Partner  Other family member  Employer  Someone else

2. Who drives the vehicle most often?

• I am the only driver

• I drive it most often

• I share it about equally with someone else

• Someone else drives it most often

3. Will this vehicle be available for you to drive as part of this study?

 Yes  No

4. Are you willing to be the primary driver (90% of the vehicle’s use) during the study period (60 days)?

 Yes  No

5. Will you provide proof of current automobile insurance for the vehicle you will drive in the study?

 Yes  No

6. Will you provide a valid vehicle registration for the vehicle you will drive in the study?

 Yes  No

9. In an average week, about how many trips do you take over 5 miles in length? ____________

10. About how many miles do you drive per year? (or approximately how many miles did you drive last year?) ____________

    1. In case you are not sure, how many miles do you drive per week? ________

11. Do you have plans for any long-distance driving trips during the next 60 days?  Yes  No

12. What is your sex?

• Male

• Female

• Prefer not to answer

13. What is your age? __________ years

14. What is highest level of school you have completed or highest degree you have received?

 No formal schooling

 First through 7th grade

 8th grade

 Some high school

 High school graduate

 Some college

 Four-year college degree

 Some graduate school

 Graduate degree

15. What is your current marital status?

 Married  Divorced  Separated  Widowed  Single  Don’t Know

NHTSA Form 1492