Class # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 1 OMB No. 2060

- 0086 expires (##)

TELEPHONE QUESTIONNAIRE

F OR CONFIRMATORY CLASS :

VE HICLE CONTROL NUMBER _

___________ ______________ DATE ___________

ADMINISTERED BY _____________________________________________________

OWNER’S NAME ________________________________________________________

STREET ADDRESS _________________________________

_____________________

CITY _________________________STATE __________________ZIP _____________

(CALL NUMBER BELOW THAT IS MARKED WITH AN “X”)

TELEPHONE (Home) /____/_________________(Business) /____/_________________

BEST TIME TO CALL ___________________

_________________________________

DATE OF CONTACT _____________________ TIME OF CONTACT _____________________________

INDIVIDUAL CONTACTED _______________________________________________________________

TO BE COMPLETED ___________________ __ DATE AND TIME OF COMPLETION _______________

The public reporting and recordkeeping burden for this collection of information is estimated to average

20 minutes per response. Send comments on the Agency's need for this information, the accuracy of the

p rovided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of

automated collection techniques to the Director, Collection Strategies Division, US Environmental Protection Agency

(2822T), 1200 Pennsylvan ia Ave., NW, Washington, DC, 20460. Include the OMB control number in any

correspondence. Do not send the completed form to this address. Privacy Act Statement

Title 42, United States Code, Section 7451, Compliance by vehicles and engines in actual use

, authorizes the collection of this information. The prima ry use is to provide an instrument by which

individuals may indicate interest in and eligibility for participating in EPA’s Light

- Duty In

- Use

Testing Program. Additional disclosures of this information may be made pursuant to published

routine uses, inclu ding to appropriate agencies for law enforcement purposes and to contractors

working for EPA who have a need to know in the course of that work.

Providing the requested information is voluntary, but failing to do so will result in EPA’s inability to

approv e your participation in the Light

- Duty In

- Use Testing Program.Class # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 2 You have been selected from a list of vehicle owners living in the Southeastern Michigan area to participate in a study of

vehicle emissions being conducted by the U.S. Environmental Protection Agency. Your participation in this program is

strictly voluntary. Testing may take approximately 2 to 4 weeks, occasionally longer. You can choose to drop

your car off at the EPA facility or we can pick it up at your convenience at your home or workplace during

normal working hours

.

The following are incentives for participating in our program:

If your vehicle is accepted into the program, a full tank of gas and a cash in centive will be awarded. You will be

offered $20 per day if you choose to use a loaner vehicle or $50 per day if you do not need a loaner . If your

vehicle is brought to the EPA and it is rejected, you will receive a $20 payment before you leave.

If you i ncentive is $600 or more we are required to ask for your Social Security Number for tax purposes. If

you do not wish to provide your social security number, you have the option to cap the total incentive at $599.

Are you willing to provide your Social Se curity Number if your incentive is $600 or more? YES NO

If NO, would you like the option to cap your incentive at $599? YES NO

Are you willing to participate? YES NO

If you are not, may we ask why not? ______________________________

________________

IF “NO” TO EITHER QUESTION, ELMINATE THIS VEHICLE. THIS PERSON CANNOT

PARTICIPATE IN THE PROGRAM.

IF RESPONSE IS POSITIVE:

For the purpose of this study, I am going to ask you some questions about your vehicle’s maintenance

and usage history. You should answer these questions to the best of your knowledge and indicate when you are

not sure of something.Class # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 3 FOR “ JACOBS PERSONNEL” ONLY

SENTENCES IN CA PITAL LETTERS ARE INSTRUCTIONS TO THE CLERK

AND ARE NOT INTENDED TO BE READ TO THE OWN ER.

1. a. What a re the model year, transmission type, vehicle identification number and test group of

your vehicle? The test group can be found on a Vehicle Emission Control Information decal

located under the engine hood.

The test group should start wit h the letters

___ .

/ / Owner is unable to locate.

/ / Owner located. TEST GROUP

__________________

ELIMINATE IF TEST GROUP IS NOT

___

b. MODEL ____________________ VEHICLE ID NO. ________________________

MODEL YEAR _________

TR ANSMISSION: AUTOMATIC / / A IR CONDITIONED: YES / / NO / /

MANUAL / / ODOMETER MILEAGE: __________

ELIMINATE IF MILEAGE IS UNKNOWN OR OVER 90 ,000 MILES.

VEHICLES WITH MILEAGE OVER 50,001 SHOULD BE ASSIGNED TO CLASS

___ _ .

NOTE: Standards are not the same for mileage above and below 50K

c. Has the odometer ever not functioned properly? YES/ / NO/ /

If yes, approximately how long (months/miles) was it inoperable? ________________

CONSULT EPA FOR ELIGI BILITY IF THE RESPONSE IS “YES”

2. a. When and where did you obtain your vehicle? When _______________________________

Where

_________________________________________________________

b. Was the vehicle utilized as a demonstrator prior to you purc hase?

YES / / NO / / DO NO T KNOW / /

IF THE ANSWER IS YES, ELIMINATE VEHICLE. CONSULT EPA IF DON’T KNOW

c. What was the mileage at the time of purchase or lease. ______________

CONSULT EPA IF MILEAGE IS OVER 400.Class # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 4 d. Are you the orig inal purchaser or lessee of the vehicle?

YES / / NO / /

IF OBTAINED NEW, GO TO NEXT NUMBERED QUESTION. IF OBTAINED USED GO TO (e)

.

e. Have you been responsible for fueling, repairs and maintenance since the vehicle was new?

YES/ / NO/ /

IF YES, GO TO 3, IF NO, CONTINUE TO (f)

f. Do you have complete records of this vehicle’s maintenance history? YES/ /NO/ /

IF NO, ELIMINATE.

3. Was the vehicle tested in a previous EPA or General Motors emission program?

(REGULARLY REQUIRED STAT E RUN EMISSIONS CHECKS ARE NOT INCLUDED)

YES / / NO / /

CONSULT EPA FOR ELIGIBILITY IF YES.

YES NO

4. Has your vehicle ever been used as a taxi?

____ ____

5. Has your vehicle ever been used as a commercial delive ry vehicle?

____ ____

6. Has your vehicle ever been used to race in competitive speed events?

____ ____

7 . Have you ever use d your vehicle to plow snow?

_____ _____

ELIMINATE IF “YES” TO ANY POSITIVE R ESPONSE TO QUESTIONS 4 THROUGH 7

.

8 . Has the vehicle been equipped to permit towing? YES/ / NO/ /

If yes; how and by whom? __________________________________________________

9

. a. Has the vehicle been used for towing ? YES/ / NO/ /

IF RESPONSE IS “YES” GO TO “ b,” IF NOT SKIP “b”

b. What did you tow?

__________________________________________________________

c. What was the approximate weight that was towed? ___________

CONSULT WITH EPA IF OVER _________ POUNDSClass # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 5 10. Have any non

- factory parts or special dev ices been installed on your vehicle? If yes, what are the

brand s of the parts ?

Y/N Brand

a. Remote start

____ ____________________

b. Security system

____ ____________________

c. Performance computer chips

____ ____________________

d. Performance air cleaner or filter/air intake parts

____ ______________ ______

e. modifications to computerized engine control

____ ____________________

f. o ther (describe)

____________________________________________________________ _________

_____________________________________________________________________

g. SKIP FOR T005/T006 : THIS ITEM IS FOR EVAP TESTING ON PICK UP TRUCKS ONLY

Cap, t oolbox, bedliner or other structure or device mounted in the truck bed.

(Describe including the device weight)

________________________________________ _____________ ___________

____________ ____________ ____________________________________________________

CONSULT EPA IF THERE IS A POSITIVE RESPONSE FOR ANY OF THE ABOVE ITEMS.

11. a. H ave you ever used any fuel other than that recommended by the manufacturer in y our

vehicle? (ex. Diesel fuel , E85 ) YES / / NO / /

IF YES, ELIMINATE

b. Have you ever used fuel system additives?

YES/ / NO/ /

If Yes, what h ave you used and why?________________________________________

How often have you used it? ______________________________________________

When was the last time you used it? ________________________________________

IF “YES”, CONSU LT EPA FOR ELIGIBILITY.Class # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 6 12. Has the catalytic converter been removed or replaced ?

YES/ / NO/ / DON’T KNOW / /

IF YES ELIMINATE

13. Have any emission control system components been altered, m odified or disconnected? This does

not include repairs or maintenance. YES/ / NO/ /

IF YES, ELIMINATE

.

14. Has your vehicle e ver overheated? YES/ / NO/ /

STOP QUESTIONNAIRE AND E LIMINATE IF VEHICLE HAS OVERHEATED

15. a. Has your vehicle ever been involved in an accident? YES/ / NO/ /

IF YES COMPLETE QUESTIONS (b), (c), (d), and (e).

b. As a result of an accident has your vehicle ever had damage in any of the following areas?

Yes No

1) Engine........................................................................

____ ____

2) Cooling Sys tem.............................................................

_____ _____

3 ) Fuel Injection System.................................

.................. ....

_____ _____

4) Exhaust System.............................................................

_____ _____

5) Fuel Tank.....................................................................

_____ _____

6 ) Emission Control System..................................................

_____ _____

7 ) Other (Specify)..............................................................

_____ _____

c. If “yes” for any of 1 to 7 describe the damage and the circumstances of the accident.

________________________________________________________________________________________

________________________________________________________________________________________

I F THERE WAS DEFINITE DAMAGE TO ANY OF THESE COMPONENTS OR IF THE OWNER IS

UNSURE WHETHER THE ABOVE COMPONENTS WERE DAMAGED, CONSULT EPA.

d. Has the damage bee n repaired?

YES/ / NO/ /Class # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 7 e. If yes; what, when, by whom and at what cost?

What _______________________________________________________________

When _______________________________________________________________

Who ____

_______________ _______________________________ ______________

16. a. Has the “Check Engine” light (Malfunction Indicator Light) ever been on during vehicle

operation at any time other than start up?

YES/ / NO/ / IF NO, g o TO 17.

b. Has the “Check Engine” light ever been blinking while you were driving?

YES/ / NO/ /

c . Describe the circumstances of each occurrence: _____________________________________

___________________________________ _____________________________________________

d . How many miles was the vehicle driven with the light on before repairs were made? (If more than

one instance, list for each.)

_________________________________________________________________ __________

___________________________________________________________________________________________ ELIMINATE IF DRIVEN MORE THAN 1,000 MILES WHEN THE LIGHT WAS STEADY OR 100

MILES IF THE LIGHT WAS BLINKING

.

e

. What was done to repair the vehicle after the light came on?

(IF MORE THAN ONE INSTANCE, LIST FOR EACH.) _______________________

______________________________________________________________________

IF REPAIRS WERE MADE WITHIN 1,000 MILES, CONSULT E PA FOR ELIGIBILIT Y.

17. a. Has the routine maintenance

, including oil changes, been performed as instructed in the owner’ s

manual or when indicated by an indicator in the vehicle (such as a dash light)? Y N

If no, what maintenances have been missed ?

CONSULT WITH EPA IF ANY HAVE BEEN MISSEDClass # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 8 b. D o you use the oil that is recommended by the vehicle’s manufacturer?

If no, what type of oil used?

IF ANSWER TO b IS NO, CONSULT WITH EPA

18

. a. Has any unscheduled maintenance (i.e., maintenance to correc t a problem) been performed on

your vehicle in the following areas?

YES NO

Engine

_____ _____ Fuel injection

_____ _____ Tr ansmission, drive shaft, axle

_____ _____ Exhaust system

_____ _____ Ignition system/El ectrical syst em

_____ _____ Cooling system

_____ _____ Fuel tank

_____ _____ Emission control system

_____ _____ Oxygen Sensor

_____ _____ Computerized engine system

_____ _____ Other

_____ _____

b. If the answer to any of the above i t em s is yes, please describe what, why, when, and

where.

WHAT _______________________________________________________

WHY _________________________________________________________

WHEN (Date and mileage)

_________________________________________

WHERE _____________________________________________________

__

WHAT _______________________________________________________

WHY _________________________________________________________

WHEN (Date and mileage)__________________________________

_______

WHERE _______________________________________________________Class # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 9

WHAT _______________________________________________________

WHY _________________________________________________________

WHEN (Date and mileage)_____________________

____________________

WHERE _______________________________________________________

CONSULT EPA FOR ELIGIBILITY IF QUESTION (b) IS ANSWERED

19

. a. Have you had any perfor mance or driv ability problems with your vehicle?

YES / / NO / /

IF NO, GO TO NEXT N UMBERED QUESTION.

If yes, describe: ________________________________________________________

_____________________________________________________________________

b. Would the problems you described fall into any of the foll owing categories?

Never Occasionally Frequently

1) Hard Starting

_______ __________ __________ 2) Poor Cold Performance

_______ __________ __________ 3) Poor Acceleration

_______ __________ __________ 4) Hesitation

_______ __________ __________ 5) Stalling

_______ __________ __________ 6) Dieseling (after run)

_______ __________ __________ 7) Back firing

_______ __________ __________ 8) Stumbling

_______ __________ ______

____ 9) Engine Knock

_______ __________ __________ 10) Rough Idle

_______ __________ __________ 11) Engine Misfiring

_______ __________ __________ 12) Other

_______ __________ __________

Describe other pr ob lems.

____________________________________________________

c. What was done to eliminate performance problems(s)?

WHAT _______________________________________________________

WHEN (Date and mileage)_________________________________________

WHERE _______

______________________________________________ __Class # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 10

WHAT _______________________________________________________

WHEN (Date and mileage)_________________________________________

WHERE _______________________________________________________

d . How l ong did each problem exist? _________________________________________

e

. Do you still experience performance problems?

YES / / NO / /

Describe the problem

_____________________________________________________________

________ _______________________________________________________________________

IF THE ANSWER TO a ABOVE WAS YES, CONSULT WITH EPA FOR ELIGIBILITY

.

2 0

. Have you ever received notice that your vehicle was involved in a recall campaign?

NO / / YES / / approximate date __________________

2 1

. a. Describe the recall or give the recall number

_______________________

_____________________________________________________________________________________________

b. Did you take your vehicle to a dealership for the recall repair?

YES / / NO / /

2 2

. Are the original tires , which were on the vehicle when first purchased, still on the vehicle?

YES / / NO / /

.

If NO, are the tires the same size as the original? Y N Don ’t know

If not, what size were installed?

IF NO OR DON’T KNOW CONSULT WITH EPA

23 . a) Have you kept records of the maintenance and repairs performed on your vehicle?

YES / / NO / /Class # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 11 If “yes” is important that the records are brought t o the lab for review and duplication. Please give

them to the technicians when they pick up your car or when you drop it off at EPA.

b) To prepare for testing, the glove box and trunk will need to be opened by JACOBS and EPA

personnel. Frequently, reco rds pertaining to the vehicle's maintenance history are found in the vehicle.

Will you allow all records (those provided by you and those found) to be reviewed and duplicated?

YES / / NO / /

24

. EPA needs to share your maintenance records with the manufacturer to correctly test the vehicle. Do

you agree to this?

YES / / NO / /

25 . EPA will change the oil in your vehicle while it is here. Also, the fuel will be removed from the vehicle

so there is no need to have any more than needed to g et from your house to Ann Arbor.



## STOP QUESTIONNAIRE FOR CLASS T005/T006

2 6

. Have the tires ever been repaired? (e.g. flat tire repaired with a plug or a foam product, etc.)

YES / / NO / / DON’T KNOW / /

IF YES, DESCRIBE ___________

_____________________________________

CONSULT EPA IF YES OR DON’T KNOW.

2 7 . Has the vehicle had any body repairs or has it received any paintwork? If yes, state how long

ago._____

2 8 . Have any of the window s been replaced/repaired? If yes, state ho w long ago? _______

2 9 . Has the vehicle been operated on gasohol or super unleaded with ethanol within the last 30 days?

30 . Has the vehicle had any kind of rust proofing or undercoating applied to it ? If yes, how long

ago?____

3 1 . Is the vehicle eq uipped with any interior or exterior modifications such as upholstery or a vinyl roof

which were not factory installed? If yes, how long ago?

3 2 . Has the vehicle been washed with a non

- was detergent ?Class # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 12 INFORM THE OWNER THAT :

ALL VALUABLES SHOULD B E REMOVED FROM THE V EHICLE (INCLUDING TH OSE IN

THE GLOVE BOX) PRIOR TO BRINGING THE VEHI CLE TO THE LAB.Class # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 13 COMMENTS:_____________________________________________________________________________

______________________ ____________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

________ __________________________________________________________________________________

__________________________________________________________________________________________

____________________________________________________________________________________ ______

__________________________________________________________________________________________

__________________________________________________________________________________________

______________________________________________________________________ ____________________

__________________________________________________________________________________________

__________________________________________________________________________________________

________________________________________________________ __________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________ ________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

____________________________ ______________________________________________ ________________

__________________________________________________________________________________________

__________________________________________________________________________________________

______________ ____________________________________________________________________________

_____________________________ ________________________________________________________ _____Class # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 14 INFORMATION UPDATE P AGE

1) Has any maintenance been performed on your vehicle since the time the telephone questionnaire was

administered? (i.e., oil change, filters changed, spark plug change, any adjustments, etc.) Y N

If "YES", please complete the following:

What was done?

When was it done?

What was the odometer reading?

Where was it done?

2) Has any other significant incident occurred since the questionnaire was administered? (i.e., accident,

operational problems, pulled trailer, vehicle rust proofed, etc.) Y N

If "YES", please complete the following:

What happened?

When di d it happen (include odometer reading)?

How does it affect the vehicle now?

_ __________________________ ______________ _____________________

_________ Participant Signature Date Jacob’s Representative DateClass # MY Manufacturer Name Model Name Test Group Class RXXC

-

_______

EPA Form 5900

- 308 (Revised 1/17/2014 ) Page 15 2011 GM BGMXVO1.8011

Control No. T005/T006 RXX C

-

_________

VIN _______________________________

State of ________________________________ County of _____________________________

I, _________

__________________________________________________________________,

b eing first duly sworn, depose and say:

I am the owner ( ) and/or joint owner ( ) and/or principal driver ( ) of

the vehicle described in this questionnaire and have personal know ledge of all matters discussed

herein. I have read the responses to the questions stated above, and such responses are tru e and

accurate to the best of my knowledge and belief.

______________________________________

(Signature)

_ ___________________________ (Date)

Subscribed and affirmed before me, a Notary Public, and I hereby certify that I am duly authorized by

the laws of the State of Michigan, County of Washtenaw, to administer oaths.

_____________________________ _ (Seal)

Notary Public

____________________________________

(Date)

My commission expires: ______________

(Date)