Form 1398 Screening Questions

OMB Control Number: 2127-XXX

Expiration Date: XX/XX/XXXX

Screening Questions for Older Driver Rearview Video System

Research assistant will read the following statement over the phone:

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 five 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	Does Candidate Meet Eligibility for Study Participation? (Circle YES or NO)
1. What is your current age?	Age: ____ Candidate must be age 60 or older to be eligible. If younger than 60, tell participant “Thank you for your time. We need volunteers 60 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. On average, how many times do you drive per week?	Number of times: _________ Candidate must answer 3 or more to be eligible. If 2 or less, tell participant “Thank you for your time. We need volunteers who drive more frequently.” and end screening.	YES NO
6. Many vehicles now have rearview video systems to aid backing and parking. How many times per week do you typically use a rearview video system?	Number of times: _________ Used for group assignment.

NHTSA Form 1398