Form NHTSA Form 1649 NHTSA Form 1649 Health Screener

Control #: 2127-0734

NHTSA Form 1649

Exp Date 03/31/2022

Driver Alcohol Detection System for Safety: Field Operational Test

Health Screen

Submitted by:

KEA Technologies, Inc.

400 Donald Lynch Blvd, Suite 102

Marlborough, MA 01752

(508) 658 - 9416

Principal Investigator

Kelly Ozdemir, PhD. Director of Applied Sciences KEA Technologies, Inc.

400 Donald Lynch Blvd, Suite 102

Marlborough, MA 01752

(508) 658 – 9425

[email protected]

Paperwork Reduction Act Statement: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with, a 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 2127-0734. The purpose of the information collection is to collect information to provide a greater understanding of the performance of both breath- and touch-based sensors with actual dosed passengers using the technology under varying environmental conditions. The primary component of this information collection is the collection of sensor data during a Field Operational Test (FOT) involving human subjects; however, demographic information about participants and post-test information will be collected as well. The objectives of the FOT are to: (1) Determine the effectiveness of the DADSS sensors in a real-world driving environment; (2) Analyze DADSS breath- and touch-based sensors in real-world driving scenarios; and (3) Obtain technical data to further refine the DADSS Performance Specifications that will ultimately be used for system design and product development. We estimate that it will take approximately 30 minutes to one hour to complete the orientation and up to 5 hours to complete the FOT. 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 Ave, S.E., Room W45-205, Washington, DC, 20590.

1. Are you experiencing any of the following symptoms:

1. Fever or feeling feverish

2. Sore throat

3. New cough

4. Nasal congestion or new runny nose

5. Muscle aches

6. New loss of smell or taste

7. Shortness of breath

8. Diarrhea, nausea, or other GI symptoms

9. No Symptoms

2. Have you traveled outside of Massachusetts in the last 14 days?

1. Yes. Where: *

2. No (SKIP TO QUESTION 4)

*If yes:

International travel: wait minimally two weeks to schedule. Domestic travel:

3. Did you take a plane?

1. Yes*

2. No**

*Wait a week to schedule study post plane travel

**Did you drive a personal vehicle?

1. Yes*

2. No**

*yes: fine to proceed with scheduling

**no: how did you travel to this location?

4. Have you had contact in the last 2 weeks with anyone who has had the above symptoms or who has suspected or known positive COVID-19

   1. Yes*

   2. No

*Ask if they have been or are planning to get tested and verify vaccination status. Wait two weeks to schedule.

5. Do you wear a face mask or covering according to state guidelines/requirements?

   1. Yes

   2. No

Script for Positive Antigen Test

Your test for COVID-19 is positive. However, this test is not 100% definitive. The golden standard for tests is PCR tests and this test is an antigen test. We advise you to visit https://www.mass.gov/covid-19-testing to find the nearest COVID-19 testing site and to contact your doctor or visit an urgent care center if you develop symptoms and feel unwell. Until you have a PCR test, you should do the following:

• Monitor your symptoms. If symptoms develop or worsen, call your doctor’s office. If you have a medical emergency and need to call 911.

• Stay home except to get medical care. Call ahead before visiting the doctor to let the office know you had a positive antigen test. When leaving home for essential medical care, avoid public transportation, including buses, trains, ride-sharing services, and taxis.

• Separate from other people and animals in your home. This includes staying in a single room away from other people and using a separate bathroom if available. If there isn't, the bathroom should be cleaned and disinfected after you use it. Please do not allow visitors who do not have an essential need to be in the home.

• Wear a covering or mask around other people and pets, even at home. Wear a face covering or mask around other people and pets, including at home and in vehicles. If you have trouble breathing with a face covering or mask on, other people in the household should wear a face covering or mask when in the same room as you.