Form NHTSA Form 2007 NHTSA Form 2007 Candidate Screening Questions

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 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-NEW (expiration date: MM/DD/YYYY).

The National Highway Traffic Safety Administration (NHTSA) has proposed to perform research involving collecting information from the public as part of a multi-year effort to learn about human-machine interface (HMI) characteristics for systems designed to aid drivers in avoiding vehicle crashes. This research will examine refining the HMI for an effective crash avoidance warning system. It will also support NHTSA in understanding the potential safety impacts of the crash avoidance warning system HMI characteristics, potential rulemaking, and NHTSA’s vehicle safety efforts.

The average amount of time to complete the survey is 7 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.

The following questions will help us determine your eligibility for study participation.

Questions will cover: (1) personal information, (2) driving experience, and (3) health issues that may impact driving ability.

Note that we (NHTSA and TRC Inc.) will not release any personal identifying information, personal health information, or criminal history information that you provide. The information gathered will be kept confidential and stored in a password-protected database on a protected computer. Response to health-related questions will be not be stored; only a yes or no indication of whether you have a condition that does not meet study criteria will be retained. Any retained personal information will be deleted at the end of the study. While each of the following questions is required for determining eligibility, completing the survey is completely voluntary. You do not have to answer any question that you do not want to answer and can stop at any time.

1. Are you able to read, write, speak, and understand English without assistance?

   1. Yes

   2. No

2. Do you have normal, or corrected-to-normal vision (e.g., corrective lenses, contacts, surgery, etc.) in both eyes?

   1. Yes

   2. No

3. Do you wear glasses or contacts?

   1. Yes

   2. No

4. (Only if question 3 is answered yes) What type of glasses or contacts do you wear?

   1. Single-focus glasses or contacts

   2. Bi-focal glasses or contacts

   3. Tri-focal glasses or contacts

   4. Progressive lens glasses or contacts

5. (Only if question 3 is answered yes) If you wear glasses, do they have transition (photochromic) lenses that darken in sunlight?

   1. Yes

   2. No

6. Do you have normal, or corrected-to-normal hearing (e.g., surgery, hearing aids, etc.) in both ears?

   1. Yes

   2. No

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

   1. Yes

   2. No

8. Do you currently have any of the following medical issues that may impact your ability to drive continuously for a 2-hour period?

• Current inner ear, dizziness, vertigo, or balance problems

• Current respiratory disorder/disease or any condition that requires oxygen

• Any epileptic seizures or lapses of consciousness within the past 12 months

• Condition or injury resulting in decreased motor control or cognitive ability condition that might affect your ability to concentrate while driving, such as Attention-Deficit/Hyperactivity Disorder (ADHD) or anxiety

1. Yes

2. No

9. Do you currently work for or are you retired from an automotive manufacturer?

1. Yes If yes, which company: ______________________

2. No

10. Have you had any criminal convictions in the past 3 years?

    1. Yes

    2. No

11. Study participants must have no more than 2 points on their driving record. Please enter your driver license number so that your driving record status can be confirmed:

12. Availability for participation:

    1. Do you have a preferred time of day for participation?

	Morning	Afternoon	Evening	Any Time
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Tues				
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Fri				
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Sun				

Please enter your contact information so we can match your responses with the information you’ve already submitted and contact you to schedule your participation.

13. Name:

1. First:

2. Middle:

3. Last:

14. Address:

4. Street Address: _____________________________

5. City: _____________________________________

6. Zip: ______________________________________

15. E-mail address:

16. Phone number:

7. Home / Land Line:

8. Mobile:

17. Can we use text messaging to help with scheduling?

    1. Yes

    2. No

Thank you! Please submit your answers now.

Submit

NHTSA Form 2007 5

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