Form 1400 Visual Scanning Training Screening Questions

OMB Control Number: 2127-XXX

Expiration Date: XX/XX/XXXX

Screening Questions for Visual Scanning Training for Older Drivers

The Continuous Care Retirement Community Administrator will post fliers around the facility and will print recruiting advertisements in the monthly newsletters to residents inviting them to attend a presentation describing the proposed study. During the presentation, attendees will be invited to join the research study. Those interested in participating will be asked to stay after the presentation, and a member of the research team will ask the screening questions below to determine whether the volunteer is eligible to participate.

The member of the research team will provide the following statement to the volunteer before asking the screening questions:

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to 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 XXXX-XXXX (expiration date: MM/DD/YYYY). The average amount of time to complete the screening is 3 minutes. All responses to this collection of information are voluntary. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden send them to Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

Question	Candidate’s Response (Enter age, or circle Yes or NO)	Does Candidate Meet Eligibility for Study Participation? (Circle YES or NO)
1. What is your current age?	_________ Candidate must be age 70 or older to be eligible. If younger than 70, tell participant “Thank you for your time. We need volunteers 70 and over.” and end screening.	YES NO
2. Do you have a current valid driver’s license?	YES NO Candidate must answer YES to be eligible. If no, tell participant “Thank you for your time. We need volunteers who are licensed drivers.” and end screening.	YES NO
3. Do you use any adaptive equipment for vehicle control while driving such as hand controls for braking or accelerating or a left-foot accelerator?	YES NO Candidate must answer NO to be eligible. If yes, tell participant “Thank you for your time. We need volunteers who drive without adaptive equipment.” and end screening. (Note: after-market side-view or rear-view mirrors and seat cushions are acceptable. Do not exclude for these)	YES NO
4. Have you been advised to alter or restrict your driving habits in any way by a medical or healthcare professional?	YES NO Candidate must answer NO to be eligible. If yes, tell participant “Thank you for your time. We need volunteers who have not been advised by a medical or healthcare professional to alter or restrict their driving.” and end screening.	YES NO
5. Do you have any color vision problems?	YES NO Candidate must answer NO to be eligible. If yes, tell participant “Thank you for your time. We need volunteers who do not have color vision limitations.” and end screening.	YES NO

NHTSA Form 1400