Form 2020 Pre-Study Questionnaire

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to, 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-TBD. The average amount of time to complete this portion of the study is 5 minutes. The purpose of this document is to obtain information about the effectiveness of a training for new drivers, and it will be used to inform the development of appropriate traffic safety countermeasures. 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. SE, Washington, DC, 20590.

Pre-Study Questionnaire

(NHTSA Form 2020)

Simulator Sickness (Pre-Study)

Please indicate the severity of symptoms that apply to you right now by circling the appropriate word. Symptom 0 1 2 3
a. General discomfort None Slight Moderate Severe
b. Fatigue None Slight Moderate Severe
c. Headache None Slight Moderate Severe
d. Eyestrain None Slight Moderate Severe
e. Difficulty focusing None Slight Moderate Severe
f. Increased salivation None Slight Moderate Severe
g. Sweating None Slight Moderate Severe
h. Nausea None Slight Moderate Severe
i. Difficulty concentrating None Slight Moderate Severe
j. Fullness of head None Slight Moderate Severe
k. Blurred vision None Slight Moderate Severe
l. Dizzy (eyes open) None Slight Moderate Severe
m. Dizzy (eyes closed) None Slight Moderate Severe
n. Vertigo* None Slight Moderate Severe
o. Stomach awareness** None Slight Moderate Severe
p. Burping None Slight Moderate Severe * Vertigo is a loss of orientation with respect to vertical upright. ** Stomach awareness is a feeling of discomfort just short of nausea.
q. Are you in your usual state of health and fitness? YES	NO
r. a. Have you been ill in the past week? YES b. If yes, are you fully recovered? YES	NO NO	N/A