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APPENDIX A—SCREENING QUESTIONNAIRE

Name______________________________________________________Male/Female

Phone Numbers (Home)________________________________(Work)_______________________________

Best Time to Call______________________________________________________

Best Days to Participate__________________________

DRIVER SCREENING AND DEMOGRAPHIC QUESTIONNAIRE: ENV-IR

Note to Screening Personnel

Initial contact with the potential participants will take place over the phone. Read the following Introductory Statement, followed by the questionnaire (if they agree to participate). Regardless of how contact is made, this questionnaire must be administered before a decision is made regarding suitability for this study.

Introductory Statement

(Use the following script as a guideline in the screening interview.)

My name is _____ and I work __________. I’m recruiting drivers for a study to evaluate new night vision enhancement systems for vehicles.

This study will involve you driving different vehicles instrumented with data collection equipment on the Smart Road at night and filling out questionnaires. Participants will come in for two separate driving sessions that will last approximately 3 hours each. We will pay you 20 dollars per hour. The total amount will be given to you at the end of the second night. Would you like to participate in this study?

If the Participant Agrees

Next, I would like to ask you several questions to see if you are eligible to participate.

If the Participant Does Not Agree

Thanks for your time, would you like me to remove you from the database?

QUESTIONS

Do you have a valid driver’s license?

Yes _____ No _____
How often do you drive each week?

Every day ____ At least 2 times a week____ Less than 2 times a week_____
How old are you? ______
What is your date of birth?__________
Have you previously participated in any experiments at __________? If so, can you briefly describe the study?

     Yes _____
     Description:______________________________________________________
     No _____
How long have you held your drivers’ license? _____________________________________
Are you able to drive an automatic transmission without assistive devices or special equipment?

Yes _____ No _____
Have you had any moving violations in the past 3 years? If so, please explain.

Yes _____ ___________________________________
No _____
Have you been involved in any accidents within the past 3 years? If so, please explain.

Yes _____ ___________________________________
No _____

Do you have a history of any of the following? If yes, please explain.

Heart condition	No____	Yes________________________________
Heart attack	No____	Yes________________________________
Stroke	No____	Yes________________________________
Brain tumor	No____	Yes________________________________
Head injury	No____	Yes________________________________
Epileptic seizures	No____	Yes________________________________
Respiratory disorders	No____	Yes________________________________
Motion sickness	No____	Yes________________________________
Inner ear problems	No____	Yes________________________________
Dizziness, vertigo, or other balance problems	No____	Yes________________________________
Diabetes	No____	Yes________________________________
Migraine, tension headaches	No____	Yes________________________________

Have you ever had radial keratotomy (corrective eye surgery) or other eye surgeries? If so, please specify.

Yes_____ __________________________________________________
No_____
(Females only, of course) Are you currently pregnant?

Yes _____ No _____

(If "yes" then read the following statement to the subject: "It is not recommended that pregnant women participate in this study. However, female subjects who are pregnant and wish to participate must first consult their personal physician for advice and guidance regarding participation in a study where risks, although minimal, include the possibility of collision and airbag deployment.")
Are you currently taking any medications on a regular basis? If yes, please list them.

Yes _____ ____________________________________
No _____
Do you have normal or corrected to normal hearing and vision? If no, please explain.

Yes _____
No _____ ____________________________________

CRITERIA FOR PARTICIPATION

Must hold a valid driver’s license.
Must be 18–25, 40–50, or 65+ years of age.
Must drive at least 2 times a week.
Must have normal (or corrected to normal) hearing and vision.
Must not have participated in previous ENV or IR study.
Must be able to drive an automatic transmission without special equipment.
Must not have more than two driving violations in the past three years.
Must not have caused an injurious accident in the past two years.
Cannot have a history of heart condition or prior heart attack, lingering effects of brain damage from stroke, tumor, head injury, or infection, epileptic seizures within the last 12 months, lingering effects from respiratory disorders, motion sickness, inner ear problems, dizziness, vertigo, balance problems, diabetes for which insulin is required, chronic migraine or tension headaches.
Cannot currently be taking any substances that may interfere with driving ability (cause drowsiness or impair motor abilities).
No history of radial keratotomy (corrective eye surgery) or any other ophthalmic surgeries.

Accepted: ________

Rejected: ________ Reason:__________________________________________

Screening Personnel (print name):______________________ (Date):________

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