Form 6 Form 6 Demographic Survey

OMB Control No.: 2126-00XX

Expiration Date: MM/DD/YYYY

Compass Demographics Questionnaire

Public Burden 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 2126-00XX. Public reporting for this collection of information is estimated to be approximately 2 minutes per response, including the time for reviewing instructions, gathering the data needed, and 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 Samuel.White@dot.gov.

Participant Number:

Date:

Time:

Results of Vision Test (20/40 required to pass)

Pass Did not pass

Results of Hearing Test

Pass Did not Pass

Results of Color Vision Test

Pass Did not Pass

Basic Information

1. How old are you?

2. What is your sex? Circle one

   1. Male

   2. Female

3. Are you left or right handed?

   1. Right

   2. Left

   3. Ambidextrous

4. Is English your primary language? Circle one.

   1. Yes

   2. No

5. What is the highest level of education you have completed? Circle one.

   1. Elementary school

   2. High school or equivalent

   3. Vocational/technical school (2 year)

   4. Some college

   5. Bachelor’s degree

   6. Master’s degree

   7. Doctoral (Ph.D.) or professional (M.D., J.D., Psy.D.) degree

Driving Related Questions

6. At what age did you receive your driver’s license?

7. Can you estimate how many hours you drive in a typical week?

__________ hours per week

8. Considering your driving time in a typical week, what percentage is primarily highway driving vs. urban/rural driving (note percentages should =100%)?

% highway = % rural/urban =