Form NHTSA Form 2006 NHTSA Form 2006 Interest Response Form

STUDY: Crash Avoidance Warning System Human-Machine Interface (HMI) Research

STERLING IRB ID:

DATE OF IRB REVIEW:

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to 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 XXX (expiration date: MM/DD/YYYY). The average amount of time to complete the survey is 5 minutes. 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.

Vehicle Research Study Interest Response Form

U.S. Department of Transportation National Highway Traffic Safety Administration

This collection of information is voluntary and will be used to determine your eligibility for study participation. Respondent burden is estimated to average 5 minutes.

Any data collected relating to this study that personally identifies you or that could be used to personally identify you will be treated with confidentiality. Contact information data will be stored on password-protected directories and destroyed after the study is complete.

1. Do you have a valid U.S. driver license?

   1. Yes

   2. No

2. If your license has restrictions, please list:

3. How many miles do you typically drive per year?:

4. What make and model of vehicle do you drive most often?

   1. Make: ______________________________

   2. Model: _____________________________

   3. Model year: _________________________

5. What is your date of birth? (mm/dd/yyyy): _________

6. What sex is listed on your birth certificate:

   1. Male

   2. Female

7. Name:

   1. First:

   2. Middle:

   3. Last:

8. Address:

   1. Street Address: _____________________________

   2. City: _____________________________________

   3. Zip: _______________________________________

9. E-mail address:

10. Phone number:

    1. Home / Land Line:

    2. Mobile:

11. How did you learn about our study?

    1. TRC Website Online Ad

    2. Newspaper Print Ad

    3. Newspaper Website Online Ad

    4. Facebook Ad

    5. Friend or Relative

    6. Other (please specify): _______________

Thank you! Please submit your answers now.

Submit

NHTSA Form 2006

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Satterfield, Kelly CTR (NHTSA)
File Modified	0000-00-00
File Created	2025-05-20