0920-1441 Participant Recruitment Questionnaire

Form Approved

OMB No. 0920-1441

Exp. Date 09/30/2027

Phone Screening Script:

Thanks for your interest in this study.

Where: This study will be conducted at the NIOSH facility in Morgantown, WV.

Purpose: The purpose is to investigate effectiveness of how a robot communicates errors to human workers.

Duration: The expected duration of the study is about 4 hours.

Payment: For your time during the study, you’ll be paid at a rate of $30/hour by a Mastercard gift card.

Screening questions: Before I tell you more about the study, I will first ask you some screening questions to see if you are eligible.

1. Are you over the age of 18? _____ (Needs to be Yes)

   1. If No, end the call and say: I’m sorry but only adults over the age of 18 are eligible. Thanks for your interest.

2. Do you have experience working in manufacturing,

warehousing, or a stockroom? (Needs to be Yes)

1. If No, end the call and say: I’m sorry but we’re only recruiting people with experience working in manufacturing, warehousing, or a stockroom. Thanks for your interest.

3. Are you pregnant? _________________________________________________

   1. If Yes, state: We will be taking extra precautions to minimize risk for discomfort during the study.

4. Do you have normal or corrected to normal vision and hearing ___ _(Needs to be Yes)

   1. If No, end the call and say: I’m sorry but this disqualifies you from participation. Thanks for your interest.

5. Are you color blind? ____________ _ (Needs to be No)

   1. If Yes, end the call and say: I’m sorry but the study tasks requires you to be capable of differentiating colors

6. Do you have severe back or neck pain? ___________ _ (Needs to be No)

   1. If Yes, end the call and say: I’m sorry but this disqualifies you from participation. Thanks for your interest.

7. Simulator Sickness Questionnaire: This study will be done in virtual reality. I’m going to ask you 2 questions to predict your chances of you developing nausea from the VR simulator.

1. Have you ever used any game or system which involved virtual reality (VR)? YES | NO

If yes – have you ever had motion sickness or simulator sickness from using the VR equipment?

2. Have you ever experienced motion sickness (for example from being in a motor vehicle or plane) severe enough that you have had to stop your activity because you were sick? YES | NO

• Note: If they answer yes to either of these questions, there is a moderate chance they will get nausea during the study from the VR and they should not participate in the study.

8. Other Susceptibility Questions:

1. Do you have any conditions that where flashing or intense light might affect you, such as epilepsy, migraines, unexplained seizures, recent concussions, or light sensitivity? YES | NO

2. Do you have any neurological or vestibular issues, or have you had any recent experiences (e.g., a head injury) that affect your balance or gait? YES | NO

3. Do you have any issues affecting your physical mobility or body movements? YES | NO

4. Do you have any issues affecting your ability to move your head and look around? YES | NO

5. Do you have a history of blood pressure issues – specifically, sudden drops in blood pressure? YES | NO

• Note: If the individual answers YES to any of these questions, the potential participant will be recommended to NOT take part in the study.

What you will do: You will be asked to complete a series of tasks in a virtual reality (VR) simulator. You will wear a head-mounted display (HMD) device and hold two controllers to perform tasks that involve picking up and placing virtual objects, while interacting with virtual robots.

Prior to the study you will complete a questionnaire asking about your experience and opinion about robots. During the study, you will be asked questions about your feelings of safety and trust. These questions will be repeated multiple times during the test.

Risks: The risks involve developing nausea, discomfort from the HMD, and stress from possible breach of privacy. There is a small risk you could get a respiratory infection such as COVID-19. Steps will be taken before and during the study to eliminate these risks.

Important info:

• If you use glasses, please wear contacts the day of the study. This will make it easier to wear the VR glasses that is necessary for the experiment.

• There is guest parking at the NIOSH facility. After enrolling you into the study, we will send you an email (or call you) to confirm the scheduled date and provide you with a list of things to remember, and information about where to go for your testing session. You will also need to bring a valid state issued ID to enter the NIOSH facility.

Get contact info: Are you interested in participating?

Name: ___________________________________________________________________

Phone: ­___________________________________________________________________

Email: ____________________________________________________________________

Time/Date of test: _________________________________________________________

Public reporting burden of this collection of information is estimated to average XX minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-1441).