Enhanced Night Visibility Series, Volume XIV: Phase III—Study 2: Comparison of Near Infrared, Far Infrared, and Halogen Headlamps on Object Detection in Nighttime Rain
PDF files can be viewed with the Acrobat® Reader®
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-DISABILITY GLARE
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 at vehicle instrumented with data collection equipment on the Smart Road at night and filling out questionnaires. Participants will come in for one driving session that will last approximately 3 hours. We will pay you 20 dollars per hour. 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
- 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 the [contractor facility]? 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 with 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 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 12 months, 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):________
|
