Form NHTSA Form 1283 NHTSA Form 1283 Demographic Questionnaire

OMB Control No. 2127-XXXX

Expiration Date xx/xx/xxxx

Demographic Questionnaire

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 response, 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, 1200 New Jersey Ave, S.E., Washington, DC, 20590

Subject #______

Supplemental Subject Information

All of this information is kept strictly confidential. We will protect all personally identifying data and information collected in connection with this study to the extent provided by law. Please note that your name is not used in any published reports, or when reporting any results.

Name: _______________________ Sex: Male Female (Circle One)

Home Address: _________________________________________________

_________________________________________________

Work Address: _________________________________________________

_________________________________________________

Times at work: ­­­­________________________

Occupation: ________________________________

(if student, note major; if retired, note former occupation)

Highest Education Level Completed (Circle One)

High school Some college Bachelor’s degree Master’s degree MD/JD/Ph.D.

Current Phone Numbers: Home (_____) _____ - _____ Work (_____) _____ - _____ Cell (_____) _____ - _____

Email address: ______________________

Birth date: ______________ Current Age: _____

Driver’s License Number: ________________________

Type of car Primary: Year _____ Make _________ Model __________

you drive: Secondary: Year _____ Make _________ Model __________

(if applicable)

What types of safety systems available in your current personal vehicle (circle all applicable):

Forward crash warning; Lane departure warning; Adaptive Cruise Control; Blind spot detection

How many years have you been driving? _____

Approximate total mileage driven over the past year: ­­­­_______________

On average, how many trips do you drive per week? _____

What is the average duration of each trip?_____

Do you wear glasses? Yes No Contacts? Yes No

NHTSA Form 1283