Form 1 Form 1 Recruitment Response Including Eligibility Screening

Study of Warning Devices for Stopped Commercial Motor Vehicles

Recruitment Response Including Eligibility Screening

IC-1: Recruitment Response

OMB:

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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 11 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.


(IRB XXXX): Compass Study – Full Ad:

VT Newsletter Ad, News, Electronic Media


Title 1: Participate in a Research Study with VTTI

Title 2: Drive a Research Vehicle on a Smart Road Course



From: Virginia Tech Transportation Institute

The Virginia Tech Transportation Institute (VTTI) is seeking healthy individuals aged 18-80 with valid U.S. driver’s licenses to participate in a research study. Preference for those that do not wear eyeglasses; contacts are fine.


Participants will drive a research vehicle on a closed test course at VTTI. The purpose of the study is to evaluate a wearable eye tracking technology during driving across a variety of real-world driving scenarios. A trained researcher will be with participants the entire time. Total participation time consists of one session lasting approximately 2 to 2.5 hours either during the day or at night.

Participants will receive up to $87.50 based on full participation.


To learn more, contact XXX-XXX-XXXX or drivers@vtti.vt.edu and reference “the Compass Study” in the message.

<IRB #XXXX>



(IRB 21-267): Compass Study – Condensed Ads:

VT Newsletter Ad, News, Electronic Media (Newsletters, FaceBook, Instagram)


Title 1: “VTTI Research Study Seeks Drivers of all Experience Levels for Research”

Title 2: “Drive a Research Vehicle on the Smart Road – Compensation offered”

Title 3 (VTTI’s website – list of studies): “Drive a Research Vehicle on the Smart Road”



Body Example 1:

VTTI is seeking individuals aged 18-80 to participate in a research study. Participants will drive a research vehicle on a closed test course at VTTI. The purpose of the study is to evaluate a wearable eye tracking technology during driving across a variety of real-world driving scenarios. Preference for those that do not wear eyeglasses while driving; contacts are fine. Total participation time consists of one session lasting approximately 2 to 2.5 hours either during the day or at night. This project provides compensation up to $87.50.


To learn more, contact XXX-XXX-XXXX or drivers@vtti.vt.edu and reference “the Compass Study” in the message.

<IRB #XXXX>



Body Example 2:

VTTI is seeking individuals aged 18-80 to participate in a research study. Participants will drive a research vehicle on a closed test course at VTTI. The purpose of the study is to evaluate a wearable eye tracking technology during driving across a variety of real-world driving scenarios. Preference for those that do not wear eyeglasses while driving; contacts are fine. Total participation time consists of one session lasting approximately 2 to 2.5 hours either during the day or at night. This project provides compensation.


To learn more, contact XXX-XXX-XXXX or drivers@vtti.vt.edu and reference “the Compass Study” in the message.

<IRB #XXXX>



Body Example 3:

VTTI is seeking individuals aged 18-80 to participate in a research study. Participants will drive a research vehicle on a closed test course at VTTI. The purpose of the study is to evaluate a wearable eye tracking technology during driving across a variety of real-world driving scenarios. Preference for those that do not wear eyeglasses while driving; contacts are fine. Total participation time consists of one session lasting approximately 2 to 2.5 hours either during the day or at night.


To learn more, contact XXX-XXX-XXXX or drivers@vtti.vt.edu and reference “the Compass Study” in the message.

<IRB #XXXX>





Compass (IRB #XXXX): Appointment Reminder Script


Script for leaving a reminder message (by phone):


Hello, this is ______________ calling from Virginia Tech Transportation Institute to remind you of your appointment to participate in the ‘Compass’ research study. You are scheduled for ______ am/pm tomorrow, ______________ (ex. Tuesday, September 14th). Please remember to have the following items available:


  • Please bring your valid U.S. driver’s license; a researcher will ask to see the license

  • Please bring reading glasses, if needed for paperwork, and wear your contacts if needed for driving; you will not be allowed to wear glasses while driving the research vehicle.

  • Please dress comfortably and wear closed-toe shoes, as no flip-flops, sandals, or high heeled shoes will be allowed

  • If you have a Master Card from a previous study, please bring that with you as well and VTTI will do their best to load the funds onto the same card


We have a very tight schedule, please arrive on time to VTTI at 3500 Transportation Research Plaza, Blacksburg. If you cannot keep this appointment for any reason please give us a call as soon as possible, so we may find another volunteer to attend. Call us at xxx-xxx-xxxx. If you have any questions, please call, xxx-xxx-xxxx.


Reminder script for speaking directly with a Compass Study participant:

Hello, this is ______________ calling from Virginia Tech Transportation Institute to remind you of your appointment to participate in the ‘Compass’ research study. You are scheduled for ______ am/pm, tomorrow ______________ (ex. Tuesday, September 14th). Please remember to bring:


  • Please bring your valid U.S. driver’s license; a researcher will ask to see the license

  • Please bring reading glasses, if needed for paperwork, and contacts if needed for driving; you will not be allowed to wear glasses while driving the research vehicle .

  • Please dress comfortably and wear closed-toe shoes, as no flip-flops, sandals, or high-heels will be allowed

  • If you have a Master Card from a previous study, please bring that with you as well and VTTi will do their best to load the funds onto the same card


We have a very tight schedule, please arrive on time to VTTI at 3500 Transportation Research Plaza, Blacksburg. If you cannot keep this appointment for any reason please give us a call as soon as possible, so we may find another volunteer to attend. Call us at xxx-xxx-xxxx. If you have any questions, please call, xxx-xxx-xxxx.


Do you have any questions? If yes… (Answer if possible or have someone give them a call) That’s a good question, I’ll find out and have someone give you a call. What would be a good time for us to call you? Thank you and have a good: day/evening.


(IRB #XXXX) Reminder script via Text Message with a Compass participant:

Hello, from VTTI. This is a reminder of your appointment to participate in the “Compass” project tomorrow at XXXXX, XXXXX am/pm. If you cannot make this appointment, please contact VTTI as soon as possible so we may find another participant to fill the slot. An email with instructions was sent previously. Please call XXX-XXX-XXXX with any questions or cancelations.

2nd Text: Please respond, “Confirm”. Thank you!


Compass (IRB #XXXX): Leave a Message Phone Script for Recruiting

Phone script for leaving a message (speak slowly):

Hello, my name is ________________ and I am calling from the Virginia Smart Roads at the Virginia Tech Transportation Institute in Blacksburg, VA. We are seeking healthy individuals to participate in a research study here at the VTTI facility. You would drive a research vehicle on a closed-to-the-public test course here while wearing instrumented glasses that track eye movements. This project provides compensation of up to $87.50 and would require coming in for one session which lasts around 2 to 2.5 hours. We will be scheduling day and nighttime sessions.


If you or someone you know are interested and would like to hear more, please call ________ at XXX-XXX-XXXX. Again, please contact XXX @ XXX-XXX-XXXX and mention the Compass Study.


Thank you and have a great day.



Compass (IRB #XXXX): More Information Email


Subject Line: More Information for VTTI Research Study, “Compass”


Hello ____________________


Thank you for your interest in our research study, Compass (IRB #XXXX)! This project is recruiting drivers, with valid U.S. licenses, aged 18-80. Preference for those that do not require eyeglasses while driving; contacts are fine.


The Virginia Tech Transportation Institute, here at the Virginia Smart Roads, in Blacksburg, VA is recruiting healthy individuals to participate in a research study. The purpose of the study is to evaluate a wearable eye tracking technology during driving across a variety of real-world driving scenarios.


This study involves participating in one session, lasting approximately 2 to 2.5 hours. Participants will be assigned to either a daytime or nighttime session, not both. If eligible, you will be asked to drive a research vehicle, a passenger vehicle, on a closed-to-the-public test course here. You will drive on a street course which mimics an urban environment and the Smart Road Highway course.


Participants will be asked to drive the research vehicle, at speeds up to 55mph on the Highway course and up to 25mph on the urban course. Participants will encounter other vehicles or objects on or near the road, similar to real-world driving scenarios.


A trained experimenter will always be in the vehicle with you. The vehicle is equipped with data collection equipment which records video data while you are in the vehicle. Other vehicles operated by trained VTTI staff will be on the closed course as part of the study. Prior to the drive portion, you will need to complete paperwork, a simple vision and hearing test and be fitted properly with the eye tracking technology. This device will be worn similarly to a pair of eyeglasses. The lenses are clear, and the device will not occlude your vision while you drive. For those that require some vision correction, snap-on vision correctors are available for some prescriptions (not all). Wearing your own eyeglasses or sunglasses while driving isn’t allowed for this project; contacts are fine.


This project provides compensation up to $87.50 for full participation, with a MasterCard.


Please call us at XXX-XXX-XXXX to go through the telephone screening, which will take approximately 10 - 15 minutes. Or you may send an email to ___________________________________with your phone #, time and date, that is best for us to call and we will be happy to contact you.


If you leave a message, please mention the “Compass” project as the subject of your message. Let us know if you have any questions.


Sincerely, _______________________

Project Assistant

Virginia Tech Transportation Institute

3500 Transportation Research Plaza

Blacksburg, VA 24061

Email: _______________________________

Work: _______________________________


Please note that VTTI holds normal business hours. Any correspondence received after 5:00pm will be attended to on the next business day.


Confidentiality Notice: The preceding e-mail message (including any attachments) contains information that may be confidential, protected by applicable legal privileges, or constitute non-public information. It is intended to be conveyed only to the designated recipient(s). If you are not an intended recipient of this message, please notify the sender by replying to this message and then delete it from your system. Use, dissemination, distribution, or reproduction of this message by unintended recipients is not authorized and may be unlawful.

Compass (IRB #XXXX): Appointment Confirmation Letter


Email subject line: “VTTI Appointment Confirmation for the “Compass” Study”


Dear ________,


Please respond to this e-mail/mail to let us know that you received it, and you were able to open and view the attached Consent. There is no need to print this form, we simply ask you to take the time to review it prior to your appointment.


We have you scheduled to come in to VTTI on <XXXX>, for the “Compass” study (IRB #XXXX). Appointments will have to be rescheduled if there is inclement weather. If this occurs, the research staff will call you as soon as possible before your scheduled appointment time.


  • Please bring your valid U.S. driver’s license; a researcher will ask to see the license

  • Please bring reading glasses, if needed for paperwork, and contacts if needed for driving

(you will not be allowed to wear glasses while driving the research vehicle)

  • Please dress comfortably and wear closed toe shoes, as no flip-flops, sandals, or high heels will be allowed

  • Please bring your MasterCard if you have one from previous participation in a study; VTTI will do their best to load the funds onto the same card



We have a very tight schedule, please arrive on time. If you can’t keep this appointment for any reason please give us a call as soon as possible, so we may find another volunteer to attend. If you have any questions, please call, xxx-xxx-xxxx.

 

Directions: Our address is VTTI, 3500 Transportation Research Plaza, Blacksburg, VA, 24061.

<This link is our correct location: https://goo.gl/maps/8b2MP3YicCt


From I-81N or S

  • Take Exit 118B to Rt. 460W

  • Follow signs to Virginia Tech/Blacksburg

  • Take Exit 5AB (Smart Road/Industrial Park Drive)

  • Follow 5A to the Right on Exit ramp to Industrial Park Drive

  • Turn Right at end of ramp onto Industrial Park Drive

  • Then make an immediate Right onto Transportation Research Plaza and

  • Make first Left and come up the hill

  • Turn Right at top of hill and at the roundabout and

  • Look for the parking spaces designated for participants or park anywhere


From 460E

  • Take Exit 5B

  • On ramp, bear Left onto 5B toward Blacksburg

  • Turn Left at light at end of ramp onto Main Street

  • Turn Right at first light onto Industrial Park Drive

  • Turn Right immediately after passing exit ramp from 460W (at large blue sign) onto Transportation Research Plz

  • Make first Left and come up hill

  • Turn Right at top of hill at the roundabout and

  • Look for the parking spaces designated for participants or park anywhere



The Main Entrance to VTTI is in the multi-story building, there is a reception desk in the lobby; please check in or call 540-231-1500 and inform the staff you are here for the “Compass” study. Again, if you have any questions, please don’t hesitate to give us a call, XXX-XXX-XXXX.



We look forward to seeing you.



Screening Date _________________ Screener _____________ Screening #: ________________



(IRB #) Compass Telephone Script and Screening Questionnaire



Eligible: Yes No


Note to Researcher:

Initial contact between participants and researchers may take place over the phone. If this is the case, read the following Introductory Statement, followed by the questionnaire. Regardless of how contact is made, this questionnaire must be administered verbally before a decision is made regarding suitability for this study.


Introductory Statement:

After a prospective participant calls or you call them, use the following script to guide you through the screening interview.


Hello. My name is _____ and I am with the Virginia Tech Transportation Institute, here at the Virginia Smart Roads, in Blacksburg, VA. We are recruiting healthy individuals to participate in a research study. The purpose of the study is to evaluate a wearable eye tracking technology while driving across a variety of real-world driving scenarios.


This study involves participating in one session, lasting approximately 2 to 2.5 hours. Participants will be assigned to either a daytime or nighttime session, not both. If eligible, you will be asked to drive a research vehicle, a passenger vehicle, on a closed-to-the-public test course here.

Participants will drive the research vehicle on both a street course which mimics an urban environment and the Smart Road Highway course, at speeds up to 55mph on the Highway and up to 25mph on the urban course. Participants may encounter other vehicles on or near the road, similar to real-world driving scenarios.

A trained experimenter will always be in the vehicle with you. The vehicle is equipped with data collection equipment which records video data while you are in the vehicle. Other vehicles operated by trained VTTI staff will be on the closed course as part of the study.

Prior to the drive portion, you will need to complete paperwork, a simple vision and hearing test and be fitted properly with the eye tracking technology. This device will be worn similarly to a pair of eyeglasses. The lenses are clear, and the device will not occlude your vision while you drive. For those that require some vision correction, snap-on vision correctors are available for some prescriptions. Wearing your own eyeglasses or sunglasses while driving isn’t allowed for this project; contacts are fine.


This project provides compensation up to $87.50 for full participation, with a MasterCard.

Any questions yet?

If they indicated that they are not interested: Thank you for your time.

If they indicated that they are interested:

If you are interested in participating, I need to go over some screening questions to see if you meet all the eligibility requirements of this study. This should take about 10-15 minutes. Any information given to us will be kept secure and confidential.

Do I have your consent to ask the screening questions?



Participant Eligibility Questions:



  1. Do you currently hold, a valid U.S. driver’s license, which you can present at the time of the study?

YES _____ NO _____

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

b. Does your license have restricted driving privileges?  YES _____ NO _____


Criterion: they are ineligible to participate if unable to present a VALID U.S. driver’s license at their appointment and they must be an experienced U.S. driver (at least 2 years).

Cannot have a license with restricted driving privileges, for example, only allowed to drive to work and home. Receiving compensation to be a participant doesn’t qualify as ‘work’. A “Restriction” such as requires corrected lenses is something different and may be considered eligible for this study.

NOTE: They will be reminded they must present a U.S. driver’s license at their appointment if scheduled.

  1. What is your current age? _______________


Criterion: Must be 18 to 80 years of age to participate.


  1. Do you have normal, or corrected to normal, vision in both eyes? YES _____ NO _____



  1. You will be asked to participate without eyeglasses or sunglasses (Contacts are fine).

Will this present a problem should you be eligible to participate? YES _____ NO _____

  1. Will you be comfortable wearing instrumented glasses while driving? YES _____ NO _____

Note: They have clear lenses and will not obstruct your vision in any way.

VTTI will clean and disinfect the glasses between participants.

You will be allowed to take breaks if necessary.

  1. If you require corrective lenses and do not have contacts, are you comfortable with VTTI fitting you with snap-on vision correctors for the instrumented glasses you’ll be wearing while driving? You will need to pass a vision test of at least 20/40, while wearing the device, to proceed to the driving phase of the experiment. YES _____ NO _____



Notes: _________________________________________________________________________________


Criterion: Must have normal or corrected to normal vision in both eyes. Must not wear glasses while driving. (need to wear instrumented glasses and be able to capture eye movements) Contacts are okay. Must be able to pass a vision test, cannot simply agree not to wear their glasses during the session.

When scheduling, preference will be for those that do not require corrective lenses (contacts are ok). If they need corrective lenses, must agree to be fitted with snap-on vision correctors for the instrumented glasses. If they are unable to pass a vision test of 20/40 during the fitting, they will be paid the minimum compensation ($35) and dismissed.

Must be comfortable wearing the instrumented glasses throughout the entire session (while driving).

  1. On average, how many days per week do you drive? ___________________________


Criterion: Must drive at least 2 days per week on average.

  1. Are you a U.S. Citizen? YES ____ NO ______ 

If No, are you a permanent resident with a valid green card to work anywhere in the U.S.?

YES ____ NO ______

To clarify, Are you a Visa holder or do you have a Valid Green Card with permanent resident status?

Visa ____ Green Card ____

If you have a Visa you will not be eligible to participate. Those with a Permanent Resident Green Card are eligible.

Notes:___________________________________________________________________________


Criterion: Must be a U.S. citizen or permanent resident (green card holder able to work anywhere in the U.S. with NO restrictions such as limit on number of hours he or she can work each week or place he or she is allowed to work, for example, he or she can’t be limited to only working at 1 company or VT only). Visa holders are not eligible.

  1. If selected to participate in this study, you will be asked to provide your SSN. Will you complete a W-9 for payment purposes as required by Virginia Tech at the time of participation? YES _____ NO _____

(for payment documentation and tax recording purposes VA Tech will require them to complete a W-9)


Please note: VA Tech would never require your SS # or any personal banking information during a phone call. If scheduled to participate in any type of study, VT would send instructions whether you need to bring personal information for an appointment, in order to complete required paperwork at a study location.

Criterion: Must be willing to complete a W-9 and to provide SSN number for payment purposes.

  1. Are you available to participate in either a nighttime or daytime session, lasting about 2 to 2.5 hours?

YES _____ NO _____


If yes, are you comfortable with driving a research vehicle on a closed test course either in the day or nighttime? __________________________________________________________


Comments on availability, if any: ___________________________________________________


Must be available to participate in a daytime or nighttime session (after dark). Note times of availability. VTTI will assign day vs night in accordance with the participant’s comfort driving during day vs night. For example, if the volunteer expresses, they are not comfortable driving at night, they will not be assigned a night session.

  1. Are you comfortable reading, writing, and speaking English? YES _____ NO _____


Criterion: Must be comfortable reading, writing, and speaking English.

NOTE: If the screener finds during the phone interview, the caller is struggling with their ability to communicate fluently in English, the screener may determine the caller as ineligible.


We need to ask a few questions about your medical history…

Do you have a history of any of the following medical conditions? If yes, please explain

  1. Do you have any mobility limitations which may cause you to require assistance getting in and out of the motor vehicle or walking to and from the building and out to the test vehicle? YES _____ NO _____

  1. Are you able to drive an automatic transmission without assistive devices or special equipment?

YES _____ NO _____


NOTES: ____________________________________________________________________________

Criterion: Must not require assistance to walk out to the vehicle or getting in and out of a motor vehicle – no mobility limitations. No leg braces, or ankle/foot in a brace/boot, etc. Must be able to drive an automatic transmission without assistive devices or special equipment.

  1. Any current heart conditions that limit your ability to participate in certain activities? YES ___ NO __

If yes, please explain:______________________________________________________________


Cannot have a heart condition which limits their ability to participate in certain activities. Cannot have suffered a heart attack or heart related ‘event’ in the past 6 months.

  1. Any history of neck or back conditions, or injury to those areas? YES _____ NO _____


If yes, please explain:______________________________________________________________


    1. If yes, does this limit your ability to participate in certain activities, even outside of driving-related activities? YES _____ NO _____



Cannot have a history of neck or back conditions which still limit their ability to participate in certain activities.

  1. Any Head Injury, Stroke, or illness or disease affecting the Brain? YES _____ NO _____


If yes, please explain:______________________________________________________________

Cannot have a history of brain damage from stroke, tumor, head injury, recent concussion, or disease or infection of the brain. Cannot have suffered a stroke or illness, etc of the brain in the past 6 months.

  1. Do you currently have uncontrolled Diabetes? YES _____ NO _____


Cannot have uncontrolled diabetes (frequent low/high blood sugar levels that they are struggling to keep regulated). Cannot have been recently diagnosed or have been hospitalized for this condition or incurred any changes in their insulin prescription during the past 3 months.

  1. Current respiratory disorder/disease or any condition which requires oxygen? YES _____ NO _____ Notes:_______________________________________________________


Cannot have current respiratory disorder/disease or disorder/disease requiring oxygen beyond sleeping.

  1. Chronic migraines or tension headaches? YES _____ NO _____

If yes, do they occur more than once a month on average? YES _____ NO _____

Notes: ___________________________________________________________________________


Cannot have, on average, more than one migraine or severe headache per month during the past yr.

  1. Any Epileptic seizures or lapses of consciousness within the last 12 months? YES _____ NO _____ Notes:_______________________________________________________


Cannot have had seizures or lapses of consciousness in the last 12 months.

  1. Current problems with the inner ear? Any dizziness, vertigo, or balance problems? YES _____ NO _____


Cannot have current problems with inner ear, dizziness, vertigo, or balance .

  1. Have you had any major surgery within the past six months, including any eye procedures?

YES _____ NO _____

If yes, explain: __________________________________________________________________


Must not have had any major surgery within the past 6 months (including eye procedures).

  1. Are you currently taking any medicines or substances that may cause drowsiness or impair your driving ability? YES _____ NO _____


Cannot currently be taking any substances that may interfere with driving ability (cause drowsiness or impair motor abilities)

  1. (Females only) Are you currently pregnant? YES _____ NO _____


If “yes,” politely inform the participant: “while being pregnant does not disqualify you from participating in this study, you are encouraged to talk to your physician about your participation to make sure that you both feel it is safe”.  If you like, we can send you a copy of the Consent Form to discuss with your physician. (Answer any questions)

Can still participate but encourage them to speak with their doctor first.

  1. Do you have normal, or corrected to normal, hearing? YES _____ NO _____


Criterion: Must be able to hear and follow researcher’s verbal directions while driving.

Must have normal or corrected to normal hearing.

  1. Have you been involved in any automobile accidents in the past 3 years? YES _____ NO _____

If so, please explain: _______________________________________________________


Criterion: Must not have been convicted of an injurious accident (driving violation) in the past 3 years.

  1. Have you had any moving violations in the past 3 years? If so, please explain. YES ___ NO ____


Criterion: Must not have been convicted of more than two driving violations in the past 3 years.


  1. Did you previously participate in a VTTI study titled “Bermuda” which was conducted between December 2021 and March 2022?


Additional info about Bermuda study in case they are unsure: The goal of the Bermuda study was to evaluate an

alternative warning device (a flashing beacon) for emergency-stopped CMVs.


If the answer is YES, participant is ineligible to participate in this study.

First, for research purposes, I’ll ask you to provide your sex and ethnicity for me. What is your sex, Male or Female?  _________


Screener - Please select all that apply:


  • Second, for research purposes, what is your race and/or ethnicity? Select all that apply.


  • Asian? Yes No

    • If “yes”:

    • Chinese? Yes No

    • Asian Indian? Yes No

    • Filipino? Yes No

    • Vietnamese? Yes No

    • Korean? Yes No

    • Japanese? Yes No

    • Another Group? For example, Pakistani, Hmong, Afghan, etc. Yes No

      • If “yes”, record the answer: _________________________________


  • Black or African American? Yes No

    • If “yes”:

    • African American? Yes No

    • Jamaican? Yes No

    • Haitian? Yes No

    • Nigerian? Yes No

    • Ethiopian? Yes No

    • Somali? Yes No

    • Another Group? For example, Trinidadian and Tobagonian, Ghanian, Congolese, etc. Yes No

      • If “yes”, record the answer: _________________________________


  • Hispanic or Latino? Yes No

    • If “yes”:

    • Mexican? Yes No

    • Puerto Rican? Yes No

    • Salvadoran? Yes No

    • Cuban? Yes No

    • Dominican? Yes No

    • Guatemalan? Yes No

    • Another Group? For example, Colombian, Honduran, Spaniard, etc.? Yes No

      • If “yes”, record the answer: _________________________________


  • Middle Eastern or North African? Yes No

    • If “yes”:

    • Lebanese? Yes No

    • Iranian? Yes No

    • Egyptian? Yes No

    • Syrian? Yes No

    • Iraqi? Yes No

    • Israeli? Yes No

    • Another Group? For example, Moroccan, Yemeni, Kurdish, etc.? Yes No

      • If “yes”, record the answer: _________________________________


  • Native Hawaiian or Pacific Islander? Yes No

    • If “yes”:

    • Native Hawaiian? Yes No

    • Samoan? Yes No

    • Chamorro? Yes No

    • Tongan? Yes No

    • Fijian? Yes No

    • Marshallese? Yes No

    • Another Group? For example, Chuukese, Palauan, Tahitian, etc.? Yes No

      • If “yes”, record the answer: _________________________________


  • American Indian or Alaska Native? Yes No

    • If “yes”:

    • Navajo Nation? Yes No

    • Blackfeet Tribe of the Blackfeet Indian Reservation of Montana? Yes No

    • Native Village of Barrow Inupiat Traditional Government? Yes No

    • Nome Eskimo Community? Yes No

    • Aztec? Yes No

    • Maya? Yes No

    • Another Group? Yes No

      • If “yes”, record the answer: _________________________________



  • White? Yes No

    • If “yes”:

    • English? Yes No

    • German? Yes No

    • Irish? Yes No

    • Italian? Yes No

    • Polish? Yes No

    • Scottish? Yes No

    • Another Group? For example, French, Swedish, Norwegian, etc.? Yes No

      • If “yes”, record the answer: _________________________________


How did you hear about this project? ___________________________________________



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