OMB#: 2127-xxxx
Expiration Date:xx/xx/xxxx
Older Drivers and Navigation Systems
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2127-XXXX. Public reporting for this collection of information is estimated to be approximately 10 minutes per interview, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, W51-316, 1200 New Jersey Ave, S.E., Washington, DC, 20590
Date of Birth ___________
Sex? Male Female
Which race category best describes you? (Check one)
White Black/African American American Indian or Alaska Native
Asian Other
Are you of Hispanic or Latino origin? Yes No
Do you currently have a valid (i.e., not expired, not suspended) North Carolina driver’s license?
Yes No (Stop, you are not eligible for the study)
If yes, do you have any of the following restrictions on your license? (check all that apply)
Corrective lenses
Hearing aids
Daytime only
Limited distance from home
No interstate/highway
Adaptive (hand) controls
Alcohol interlock
Other____________________
What type of vehicle do you regularly drive?
Year ____ Make __________ Model ____________
None (Stop, you are not eligible for the study)
a. Will this vehicle be available for you to drive as part of this study?
Yes No (Stop, you are not eligible for the study)
b. Who owns the vehicle?
Self Spouse/Partner Other family member Employer Someone else
c. Do you have proof of current automobile insurance for the vehicle you will drive in the study?
Yes No (Stop, you are not eligible for the study)
(over)
In a typical week, do you drive at least 3 times?
Yes No
Which of the following statements best describes your use of in-vehicle electronic navigation systems such as built-in or add-on GPS units, Onstar®, or cell phone navigation applications? (Check one)
Have never used one myself and do not know how to use one
Have tried to use one but do not feel comfortable using one now
Use one sometimes but I don’t feel confident
Use one sometimes and I feel confident
Use one regularly and confidently
What type of electronic navigation system do you use most often? (Check one)
Built-in with map display Built-in audio only Portable dash/window mount
Cell phone Other_________ None
When you go to an unfamiliar place, what is your preferred navigation method? (Check one)
Paper Map Electronic Navigation Device Turn-by-turn directions
Passenger navigating
Your involvement in this study could include 2 visits to the East Carolina University campus each taking less than 2 hours. You will receive $50 for the first visit and an additional $100 if you are selected for and complete the second session. Are you willing to participate if chosen?
Yes No
NHTSA Form 1260
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | kathy.sifrit |
| File Modified | 0000-00-00 |
| File Created | 2021-01-26 |