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• Enhanced Night Visibility Series, Volume VIII: Phase II—Study 6: Detection of Pavement Markings During Nighttime Driving in Clear Weather

Enhanced Night Visibility Series, Volume VIII: Phase II—Study 6: Detection of Pavement Markings During Nighttime Driving in Clear Weather

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APPENDIX A—PARTICIPANT SCREENING QUESTIONNAIRE

Driver Screening and Demographic Questionnaire: ENV-Pavement Markings

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):

Good morning/afternoon! My name is _____ and I work at the Smart Road. I'm recruiting drivers for a study to evaluate new vehicle headlamps.

This study will involve you driving a car for two sessions on the Smart Road. The Smart Road is a test facility equipped with advanced data recording systems here in [contractor location]. We will pay you 20 dollars per hour. The total amount will be given to you at the end of the second 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, corrective 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 18-25, 40-50, or 60+ 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 three years.
7. Must not have caused an injurious accident in the past two 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, corrective eye surgery, or any other ophthalmic surgeries.

Accepted: ________                      Days that will attend to Study:
(T):_________(N1):_________(N2):________

Rejected: ________        Reason:__________________________________________

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