Form NHTSA Form - 1842 NHTSA Form - 1842 Vision-Hearing Form

OMB Control#: TBD Expiration Date: TBD NHTSA Form 1842

Paperwork Reduction Act Statement: 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. The information collected on this form is necessary to complete a study to examine the effectiveness of lateral control advanced driver assistance systems. We estimate that it will take approximately 5 minutes to complete this form. The information collected is 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., Room W45-205, Washington, DC, 20590.

Vision and Hearing Screening

Date: ________ Participant # __________

Lateral Control

Vision/Hearing/Measurement

1. Acuity Test (must be better than or equal to 20/40)

• Acuity Score:________

2. Ishihara Test for Color Blindness

1._____ 4._____ 7.____

2._____ 5._____ 8._____

3._____ 6._____ Book: __________

3. Hearing Test:

Repeat after me:

• A car is approaching in the left lane. ____

• Please turn right at the next intersection. ____

• The vehicle is running smoothly. ____

• The car ahead of me has its high-beams on. ____

--Driver’s license Valid YES NO