Form NHTSA Form 1625 NHTSA Form 1625 Demographic Questionnaire

OMB Control No. 2127-XXXX

Expiration Date XX/XX/XXXX

FMVSS ADS-DV Seat Preference (Study M)

Draft Demographics 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. Completing this form 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 10 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.

Participant Number:

Date:

Time:

Results of Color Vision Test

Color Vision: Passed Did not Pass

Basic Information

1. What is your age in years?

2. What is your gender?

   1. Male

   2. Female

   3. Other or prefer not to identify

3. Are you left or right handed?

   1. Right

   2. Left

   3. Ambidextrous

4. Is English your primary language? Circle one.

   1. Yes

   2. No

5. What is the highest level of education you have completed? Circle one.

   1. Elementary school

   2. High school or equivalent

   3. Vocational/technical school (2 year)

   4. Some college

   5. Bachelor’s degree

   6. Master’s degree

   7. Doctoral (Ph.D.) or professional (M.D., J.D., Psy.D.) degree

Driving Experience

6. How many years have you held a valid driver’s license?

Technology Experience

7. What smartphone do you own? Please list.

8. How long have you used a smartphone? Circle one.

   1. Under 2 years

   2. More than 2 years, but less than 4 years

   3. Over 4 years

9. Do you use your smartphone on a daily basis? Circle one.

   1. Yes

   2. No

10. What tasks do you typically perform on your smartphone? Check all that apply.

• Email

• Gaming

• Navigation

• Taking pictures

• Scheduling and calendar tasks

• Social networking

• Text messaging

• Web browsing

• Other (please list):

11. Do you currently use or have you used ride sharing applications (e.g. Uber, Lyft, etc.) in the past?

12. Have you ever ridden or driven in a vehicle that would be considered autonomous or otherwise have a driverless feature?

YES NO UNSURE

If yes, which ones:

1. Low Speed Driverless Shuttle

2. Other autonomous or driverless vehicle

13. Have you ever ridden or driven in a vehicle that has any of the following? If yes, which ones?

YES NO UNSURE

If yes, which ones:

1. Adaptive Cruise Control

2. Lane Keeping Assist

3. Lane Centering Assist

4. Tesla Autopilot

5. GM Supercruise

6. Other (please specify)

NHTSA Form 1625