NHTSA Form 1398 Screener

OMB Control Number: 2127-0731

Expiration Date: mm/dd/yyyy

Screening Questionnaire

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to 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 2127-0731 (expiration date: MM/DD/YYYY). The average amount of time to review and complete the form is 5 minutes. The purpose of this research study is to examine drivers’ use of rearview video systems. 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.

Note: Initial contact between participants and researchers may take place over the phone. If this is the case, read the following Introductory Statement, including the Paperwork Reduction Act statement, followed by the questionnaire. Regardless of how contact is made, this questionnaire must be administered 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 Virginia Smart Rds, in Blacksburg, VA.  We are currently recruiting people to participate in a research study. This study involves participating in one session, lasting about 1.75 hours during daytime hours (likely M-F, 8-5 pm). If eligible, you will be asked to drive a research vehicle on a closed to the public test course at Virginia Tech Transportation Institute and to perform various parking tasks. An experimenter will be in the vehicle with you at all times. The research vehicle is equipped with data collection equipment which records video and audio data while you are in the vehicle. Prior to the driving portion, you will need to complete paperwork, a simple vision and hearing test and be willing to perform a simple flexibility test. To do this, we will ask you to sit in a chair and move your head, neck, and shoulders as you do when you are driving.

This project provides compensation of $50, with a MasterCard, for full participation.

Any questions yet?

[Read Paperwork Reduction Act statement.]

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.]

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? ______________

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 U.S. driver (at least 2 years).

Can’t include time with a Learner’s Permit during the 2 years of experience. (Must be fully licensed for at least 2 years). NOTE: They will be reminded they must present a driver’s license at their appointment if scheduled.

2. Is your current U.S. Driver’s License “Restricted”? YES _____ NO _____

Criterion: Must present a valid driver’s license that is NOT listed as “Restricted” at their appointment if scheduled. For example, can’t be restricted to only driving to and from work. Participating in a research project doesn’t qualify as ‘work’. (A restriction, as in, needs corrective lenses, is okay)

3. On average how many days a week do you drive? ______________

Criterion: Must drive, on average, at least 3 days per week.

4. What is your current age? _______________ YOB_________

Criterion: Must be 60+years of age to participate.

5. 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 VT only). Visa holders are not eligible.

6. If selected to participate in this study, you will be asked to provide your SSN number. Will you complete a W-9 for compensation 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, VT 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 and complete a W-9 for payment purposes. VT ID will NO longer be accepted.

7. Are you available to participate in one 1.5 to 2-hour session during daylight hours (likely M-F, 8-5)? YES _____ NO _____

Note availability: ___________________________________________________

Preference for those available for a daytime session during standard business hours (Mon – Fri, 8 am to 5 pm). Note their availability. Some weekend slots or late day slots may become available.

8. Do you have any experience with any of the following vehicle features (please check all that apply)?

• Navigation system

• Voice recognition / OnStar / Ford Sync

• Advanced Cruise Control

• Rear video/Rearview Camera

• Park aid/Park Assist

• None of the above

RVS Notes: ___________________________________________________________________________

_____________________________________________________________________________________

Criterion: If they answer yes, to Rearview Camera/Video, please ask them to explain further. This phase of the project will use those without (or very limited) experience using a rear video/rearview camera system. If they simply know about RVS or have been introduced to them by somebody, or only used them once or twice (i.e., rental car, drove friend’s car), then they qualify as without/limited experience. If they have driven a vehicle with a RVS system, at some point, on a regular basis, they are not eligible for this phase of the project.

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

Must be comfortable reading, writing, and speaking English

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.

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 research vehicle?

1. Are you able to drive an automatic transmission without assistive devices or special equipment? Yes_____ No________

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, ankle/foot in a boot, etc. Must be able to drive an automatic transmission without assistive devices or special equipment.

11. Any neck or back condition or injury that still limits your ability to drive safely? YES ___ NO ___

Would you be comfortable performing backing tasks while driving a research vehicle? YES____ NO ___

Cannot have a neck or back conditions which limits their ability to drive safely. Cannot report being uncomfortable performing backing tasks.

12. Any current heart conditions that limit your ability to participate in certain activities? YES ___ NO ___

If yes, please explain:_____________________________________________________________

Cannot have a heart condition which limits their ability to drive safely.

13. 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.

14. Do you currently have uncontrolled Diabetes? YES _____ NO _____

Notes:______________________________________________________

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

15. Current respiratory disorder/disease or any condition which requires oxygen? YES ____ NO _____ Notes:______________________________________________________

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

16. Current history of 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. Any Epileptic seizures or lapses of consciousness within the last 12 months? YES _____ NO _____ Notes:______________________________________________________

Cannot have had seizures or lapses of consciousness in the last 12 months.

18. Current problems with the inner ear, dizziness, vertigo, or balance problems? YES _____ NO _____

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

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

YES _____ NO _____

If yes, explain: __________________________________________________________________

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

20. 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)

21. You will be asked to participate 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 participate without sunglasses or w/o lenses that darken while inside a vehicle. If they require glasses while driving, they need to wear glasses during this experiment.

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

Note: If you need glasses while driving, you will need to wear them during this experiment.

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

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

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

Must have normal or corrected to normal hearing.

24. The next two questions will not affect your eligibility. VTTI strives for Inclusiveness:

For research purposes, please identify your gender, race, and ethnicity for me.

Do you identify as Male, Female, or Other?    (Circle one)

“What are your preferred personal pronouns?” ____________

Which racial category or categories best describes you? You may select more than one.

Screener - Please select all that apply:

• American Indian or Alaska Native (for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Nome Eskimo Community, etc.)

• Asian (for example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc.)

• Black or African American (for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc.)

• Middle Eastern or North African (for example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc.)

• Native Hawaiian or Other Pacific Islander (for example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.)

• White (for example, German, Irish, English, Italian, Polish, French, etc.)

• A race, ethnicity, or origin not listed here ____________________

• Prefer not to answer

Regardless of your race, are you Hispanic or Latino? YES _____ NO _____

An effort will be made to recruit a variety of different races and ethnicities and participants of all genders to create a diverse sample of participants. This will be balanced across groups if possible.

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 E-mail ________________________ 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 Informed Consent Form 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:

__________________________________________________________________________

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NHTSA Form 1398