Form 9 Form 9 Study Acknowledgement Form

OMB Control No.: 2126-00XX

Expiration Date: MM/DD/YYYY

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.

Study Acknowledgement Form 

This survey is to be completed following all runs. This survey is to be administered verbally by the experimenter to the participant. Please record detailed notes and comments as appropriate. 

For each test run indicate the study condition the participant received (Baseline/triangles or Intervention/beacon): 

 

Test Run #1; Triangles: Absent Present 

Test Run #2; Triangles: Absent Present 

Test Run #3; Triangles: Absent Present 

Test Run #4; Triangles: Absent Present 

 

Read the following statement to the participant: 

We could not disclose the true purpose of today’s study up front due to the nature of data collection. We apologize for the deception but it was critical to capture your reactions and behaviors to the scenarios you encountered today (i.e. stopped CMVs and warning triangles), without knowing what we were assessing.  

The true purpose of today’s study was to test whether warning devices (i.e. warning triangles) meaningfully influence crash-relevant aspects of driving performance in the presence of a Parked or disabled commercial motor vehicles (PDCMV), and if so, how and to what extent. Now that you know the true purpose of today’s study, do you consent to take part in this research? If you decline, all data collected today will be deleted. 

 

Signatures 

Your signature documents your permission to take part in this research. We will provide you with a signed copy of this form for your records.
Signature of subject		Date
Printed name of subject
Signature of person obtaining consent		Date
Printed name of person obtaining consent