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Publication Number: FHWA-HRT-04-144
Date: December 2005

Enhanced Night Visibility Series, Volume XIII: Phase III—Study 1: Comparison of Near Infrared, Far Infrared, High Intensity Discharge, and Halogen Headlamps on Object Detection in Nighttime Clear Weather

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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 at the [contractor]. 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 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, would you like me to remove you from the database?


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. What is your date of birth?__________

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

         Yes _____
         Description:______________________________________________________
         No _____

  6. How long have you held your drivers’ license? _____________________________________

  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, [corrective eye surgery], or other eye surgeries? If so, please specify.

         Yes_____     __________________________________________________
         No_____

  12. (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.”)

  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 _____     ____________________________________


Criteria For Participation

  1. Must hold a valid driver’s license.
  2. Must be 18–25, 40–50, or 65+ years of age.
  3. Must drive at least 2 times a week.
  4. Must have normal (or corrected to normal) hearing and vision.
  5. Must not have participated in previous ENV or IR study.
  6. Must be able to drive an automatic transmission without special equipment.
  7. Must not have more than two driving violations in the past three years.
  8. Must not have caused an injurious accident in the past two years.
  9. 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.
  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, [corrective] eye surgery, or any other ophthalmic surgeries.

Accepted: ________

Rejected: ________        Reason:__________________________________________

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

 

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