Form NHTSA Form 1624 NHTSA Form 1624 Eligibility Questionnaire

OMB Control No. 2127-XXXX

Expiration Date XX/XX/XXXX

FMVSS ADS-DV Seat Preference (Study M)

Draft Eligibility Questionnaire

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-XXXX. Responding to this questionnaire is voluntary. The information collected on this form is being used for purposes of research on advanced vehicle technologies. We estimate that it will take 20 minutes to complete the questionnaire. 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.

Note:

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 Road, 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 researching the use of Ride Sharing Applications for the National Highway Traffic Safety Administration. As part of this project, we are asking individuals to help evaluate some new technology and ride in different research vehicles, on the Smart Road Highway and Surface Street, which are both part of our test tracks closed to the public. The vehicles are 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 the ride sharing application. This application will run on a study tablet or smartphone we provide that will then be used to summon the study vehicles. You will then be asked to summon and ride in each study vehicle, following a designated path on our test tracks. At the end of the study we will ask you your opinions about your experience.

This project provides compensation of $90, with a MasterCard, for full participation. Any questions yet?

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.]

Participant Eligibility Questions:

1. Do you currently hold, a valid U.S. driver’s license, which you can present at the time of the study? YES _____ NO _____ If yes, how long have you held a U.S. license? _____________

a. Does your license have restricted driving privileges?  YES _____ NO _____

NOTE: They will be reminded they must present a valid U.S. driver’s license at their appointment if scheduled.

Criterion: they are ineligible to participate if unable to present a VALID U.S. driver’s license at their appointment and they must be an experienced driver (at least 2 years).

Cannot have a license with restricted driving privileges, for example, only allowed to drive to work and home. Receiving compensation to be a participant doesn’t qualify as ‘employment’.

2. On Average how often do you use a ridesharing application? ______________

Criterion: Must have used a rideshare at least once in the past year.

3. What is your current age? _______________ YOB_________

Criterion: Must be 20-35 or 50-65 years of age to participate.

4. Are you a U.S. Citizen? YES ____ NO ______ 

If No, are you a permanent resident with a valid green card to work anywhere in the U.S.?

YES ____ NO ______

To clarify, Are you a Visa holder or do you have a Valid Green Card with permanent resident status? Visa ____ Green Card ____

If you have a Visa you will not be eligible to participate. Those with a Permanent Resident Green Card are eligible.

Notes:______________________________________________________________________

Criterion: Must be a U.S. citizen or permanent resident (green card holder able to work anywhere in the U.S. with NO restrictions such as limit on number of hours he or she can work each week or place he or she is allowed to work, for example, he or she can’t be limited to only working at 1 company or Virginia Tech only). Visa holders are not applicable.

5. If selected to participate in this study, you will be asked to provide your SSN. Will you complete a W-9 for payment purposes as required by Virginia Tech at the time of participation?

(for payment documentation and tax recording purposes VA Tech will require them to complete a W-9)

Please note: VA Tech would never require your SS # or any personal banking information during a phone call. If scheduled to participate in any type of study, VA Tech would send instructions whether you need to bring personal information for an appointment, in order to complete required paperwork at a study location

YES _____ NO _____

Must be willing to provide SSN number for payment purposes. VT ID # is no longer acceptable.

6. Have you participated in any experiments or driving studies at the Virginia Tech Transportation Institute? YES _____ NO _____

If yes, describe the study: ____________________________________________________________

Cannot have been in a similar study (one using a surprise event or deception).

7. Are you comfortable reading, writing, and speaking English? YES _____ NO _____

Criterion: Must be able to read, write, and speak English comfortably. If the screener finds during the phone interview, the caller is struggling with their ability to communicate fluently in English, then the screener should avoid scheduling this person.

1. For research purposes, do you identify as Male, Female, [pause] or other? (Circle one)

      If answer “Other”, ask, “what are your personal pronouns”? ____________

Criterion: The total number of participants will be gender balanced if possible.

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

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

9. Are you currently pregnant? YES _____ NO _____

If “yes,” politely inform the participant: “If you are pregnant, you are ineligible to participate in this study”. Answer any questions. (Pregnancy precludes Participation)

10. Do you have any mobility limitations which may cause you to require assistance getting in and out of the motor vehicle or walking to and from the building and out to the test vehicle?

YES _____ NO _____

1. Are you able to drive an automatic transmission without assistive devices or special equipment? YES _____ NO _____

NOTES: _________________________________________________________________________

Criterion: Must not require assistance to walk out to the vehicle or getting in and out of a motor vehicle – no mobility limitations. No leg braces, or ankle/foot in a brace/boot, etc. Must be able to drive an automatic transmission without assistive devices or special equipment.

11. Any history of neck or back conditions, or injury to those areas, which still limit your ability to participate in certain activities? YES _____ NO _____

If yes, please explain:______________________________________________________________

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

1. Any Head Injury, Stroke, or illness or disease affecting the Brain? YES _____ NO _____

If yes, please explain:______________________________________________________________

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

13. Current heart condition which limits your ability to participate in certain activities?

YES _____ NO _____

If yes, please explain:______________________________________________________________

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

14. Current respiratory disorder/disease or any condition which requires oxygen? YES ___ NO ___ Notes:_______________________________________________________

Cannot have current respiratory disorder/disease or disorder/disease requiring oxygen.

15. Any epileptic seizures or lapses of consciousness within the past twelve months?

YES _____ NO _____ Notes:_______________________________________________________

Cannot have had an epileptic seizure or lapse of consciousness within the past 12 months.

16. Chronic migraines or tension headaches? YES _____ NO _____

If yes, do they occur more than once a month on average? YES _____ NO _____

Notes: ___________________________________________________________________________

Cannot have, on average, more than one migraine or severe headache per month during the past yr.

17. Current problems with motion sickness, inner ear problems, dizziness, vertigo, or balance problems? YES _____ NO _____

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

18. Do you have uncontrolled diabetes? YES _____ NO _____

If yes, please explain:______________________________________________________________

Cannot have uncontrolled diabetes (frequent low/high blood sugar levels that they are struggling to keep regulated). Cannot have they been recently diagnosed or have they been hospitalized for this condition, or incurred any changes in their insulin prescription during the past 3 months.

19. Have you had any major surgery within the past six months, including any eye procedures?

YES _____ NO _____

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

20. Do you have Osteoporosis or any other weakening of bones? YES _____ NO _____

Must not have been diagnosed with Osteoporosis or other bone disorders.

21. Are you currently taking any medicines or substances that may cause drowsiness or impair your driving ability? YES _____ NO _____

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

22. Do you have normal, or corrected to normal, vision in both eyes? YES _____ NO _____

Criterion: Must have normal or corrected to normal vision in both eyes.

23. You will be asked to ride in a study vehicle 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 sitting inside a vehicle?

YES _____ NO ____

Criterion: Must be able to ride without sunglasses or w/o lenses that darken while inside a vehicle.

24. Do you have normal, or corrected to normal, hearing? YES _____ NO _____

Criterion: Must be able to hear and follow researcher’s verbal directions while riding.

Must have normal or corrected to normal hearing.

25. Are you available to participate in a 2-hour session during daylight hours (likely M-F, 8-5)? YES _____ NO _____

Comments on availability, if any: ___________________________________________________

Preference for those who can participate during the hours of M-F, 8am-5pm. Note times of availability. Some appointments may be outside of typical business hours.

26. Have you had any moving violations in the past 3 years? YES _____ NO _____

If so, please explain: ____________________________________________________________________________

Criterion: Must not have been convicted of more than two driving violations in the past 3 years.

27. Have you been involved in any automobile accidents in the past 3 years? YES _____ NO _____

If so, please explain _____________________________________________________________

Criterion: Must not have been convicted of an injurious accident (driving violation) in the past 3 yrs.

28. Do you work for an automotive company or supplier that is involved in the design, engineering, or development of automotive-related technologies?

Yes _____ No ______ If yes, who:__________

____________________________

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

29. How did you hear about this project? _______________________________________________

Recruiting Others:

Do you know anyone else that may be interested in hearing about this study?

If yes, may we send you the information so you can forward it to them? (Or they can provide our phone #, email, website address to others; we will be happy to speak to anyone interested in hearing more)

Do you prefer we send you the info by Email: ________________________ or USPS mail (address):____________________________________________________________________

If Eligible:

Availability: _______________________________________________________________

Scheduled on (date & time):________________________________________________

Name: ___________________________

Home Phone #: ______________________ Cell#________________ Work #______________

We encourage you to read a copy of the Information Sheet prior to coming in for your scheduled appointment. Please review it ahead of time and contact us with any questions or concerns. You will be asked to read & sign a copy of this document upon arrival at VTTI prior to participating. Do not bring this document with you to the appointment; we simply ask for you to review the document ahead of time and to let us know you received it. Do you prefer we send as an email attachment or by USPS?

E-mail or mailing address: _____________________________________________________

Town or city you live & approximate travel time to VTTI: __________________________________________________________________________

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

If yes, collect the following:

Last Name: ___________________________ First Name: ___________________________ Y.O.B. _______________________

Home Phone #: ______________________ Cell#________________ Work #______________

Town or city: _____________________ State: _______ Zip: ________________

Specialty Driver’s License_______________________________________________

if CDL: endorsements________________________________________

restrictions________________________________________

Make, Type and year of Primary Vehicle (light) ____________________________________

(2dr, 4dr, SUV, Truck, Van, 4X4-Off Road, Electric, Motorcycle

NHTSA Form 1624