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Publication Number: FHWA-HRT-04-136
Date: December 2005

Enhanced Night Visibility, Volume V: Phase II—Study 3: Visual Performance During Nighttime Driving in Snow

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APPENDIX A—SCREENING QUESTIONNAIRE

Driver Screening and Demographic Questionnaire: ENV-Snow

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 in italics as a guideline in the screening interview):

Good morning/afternoon! My name is _____ and I work at the Smart Road. I'm recruiting drivers for a study to evaluate new night vision enhancement systems for vehicles.

This study will involve you driving experimental vehicles for one 3 to 4 hour session on the Smart Road. The Smart Road is a test facility equipped with advanced data recording systems. It is equipped with technology that will allow us to create snow, fog, and rain. We will pay you 20 dollars per hour. The total amount will be given to you at the end of the session. Would you like to participate in this study?

If they agree:

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

If they do not agree:

Thanks for your time.


Questions

  1. Do you have a valid driver's license?

            Yes _____          No _____

  2. How often do you drive each week?

            Every day ____     At least 2 times a week____     Less than 2 times a week_____

  3. How old are you? ______

  4. Have you previously participated in any experiments at the [contractor facility]? If so, can you briefly describe the study?

            Yes _____        Description:______________________________________________________
            No _____

  5. How long have you held your drivers' license? _____________________________________

  6. What type of vehicle do you currently drive? _____________________________________

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

            Yes _____     No _____

  8. Have you had any moving violations in the past 3 years? If so, please explain.

            Yes _____      ___________________________________
            No _____

  9. Have you been involved in any accidents within the past 3 years? If so, please explain.

            Yes _____     ___________________________________
            No _____

  10. 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________________________________

  11. Have you ever had radial keratotomy, [laser eye surgery], or other eye surgeries? If so, please specify.
            Yes_____     __________________________________________________
            No_____

  12. (Females only, of course) Are you currently pregnant?
            Yes _____      No _____

  13. Are you currently taking any medications on a regular basis? If yes, please list them.

            Yes _____     ____________________________________
            No _____

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


I would like to confirm your full name, phone number(s) (home/work) where you can be reached, hours/days when it's best to reach you, and preferred days to participate.

Name __________________________________________________________    Male / Female

Phone Numbers (Home)_________________________(Work)_________________________

Best Time to Call _________________________________________________

Best Days to Participate____________________


Criteria For Participation:

  1. Must hold a valid driver's license.
  2. Must be 18 to 25, 40 to 50 years of age.
  3. Must drive at least two times a week.
  4. Must have normal (or corrected to normal) hearing and vision.
  5. Must be able to drive an automatic transmission without special equipment.
  6. Must not have more than two driving violations in the past 3 years.
  7. Must not have caused an injurious accident in the past 2 years.
  8. 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 12 months, respiratory disorders, motion sickness, inner ear problems, dizziness, vertigo, balance problems, diabetes for which insulin is required, chronic migraine or tension headaches.
  9. Must not be pregnant.
  10. Cannot currently be taking any substances that may interfere with driving ability (cause drowsiness or impair motor abilities).
  11. No history of radial keratotomy, [laser] eye surgery, or any other ophthalmic surgeries.

Accepted: ________

Rejected: ________        Reason:__________________________________________

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

Willing to drive in snow?   Y     N       Willing to come in 11 p.m. or later?   Y    N

 

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