(List Year, Make, EF# of Class here) Control #_____________________

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TELEPHONE QUESTIONNAIRE OMB No. 2060-0086

 

VEHICLE 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 

Privacy Act Statement

Authority: Title 42, United States Code Section 754

Purpose: The information on the Questionnaire, and your maintenance records if you provide 

them, will be used to help determine the emissions performance of vehicles and their effect on air 

quality. If you qualify for a cash incentive of $600 or more, EPA will ask for your social security

number to report the payment to the IRS on Form 1099.

Routine Uses: The information will be used by EPA for the purposes set forth above. If you 

approve, your questionnaire and voluntarily provided maintenance records will be shared with the 

manufacturer. Your social security number will be reported to the IRS on Form 1099 for 

payments of $600 or more.

Mandatory or voluntary disclosure and the effects on the individual of not providing 

information: Answering the Questionnaire and providing maintenance records is voluntary.

Failure to disclose the personal information requested on the Questionnaire or provide 

maintenance records may preclude your participation in this voluntary testing program. Disclosure 

of your social security number is mandatory to receive payment of $600 or more. If you are not 

willing to provide your social security number, you can not receive $600 or more for your 

participation.

DATE OF CONTACT _______________________ TIME OF CONTACT __________________

INDIVIDUAL CONTACTED_______________________________________________________

TO BE COMPLETED ___________________ DATE AND TIME OF COMPLETION___________

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including 

time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and 

completing and reviewing the collection of information. Send comments regarding the burden estimate or any other 

aspect of this collection of information, including suggestions for reducing this burden, to Chief, Information Policy 

Branch, PM-223, U.S. Environmental Protection Agency, 40l M St., S.W., Washington, DC. 20460; and to the Office 

of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC. 20503.
(List Year, Make, EF# of Class here) Control #_____________________

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You have been selected from a list of vehicle owners living in the Detroit/Ann Ann Arbor metropolitan area to 

participate in a study of vehicle emissions being conducted by the U.S. Environmental Protection Agency.

EPA is authorized by law to conduct this study and to offer incentives to you for your cooperation should you decide to 

participate. Your participation in this program is strictly voluntary.

The accuracy of the information that you provide is important. The information that you provide will be used by 

EPA along with emission results from your vehicle to determine whether the automobile manufacturer has complied 

with clean air standards established by Congress. The test results from your vehicle will not be used by EPA to take 

action against you. Your cooperation will help EPA's efforts to control air pollution due to motor vehicle emissions.

These are the conditions of the program:

- we ask that you bring or allow us to pick up and deliver your vehicle into our testing facility. You will 

receive either a cash incentive for each day we keep your vehicle or cash incentive plus a late model loaner car 

which will have a full tank of gas and unlimited mileage. This vehicle is yours to use without charge for the 

duration of the testing, which may take approximately 2 to 3 weeks. During this time, we will be performing 

a series of tests on your vehicle to measure vehicle emissions.

At the time the vehicle is delivered to us for testing, you will be required to sign an affidavit stating that the 

answers to the questions you will be asked are true and accurate to the best of your knowledge.

We will provide you the following incentives for participating in our program:

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

receive $20 per day for each day your vehicle is at NVFEL, and the use of a fully-insured loan car; or $50 per 

day for every day your vehicle is at NVFEL in lieu of a loan car.

However, if your vehicle is rejected after you bring it to the lab, but before you leave, you will receive a $20 

payment.

The compensation will be based on whole days, beginning with the day your vehicle arrives, and ending one 

day after you are notified your vehicle is ready for return.

The maintenance performed on your vehicle will depend on program requirements. 

You will be given a list of any parts that are replaced.

Are you willing to participate? YES NO 

If you are not, may we ask why not? ______________________________________________
(List Year, Make, EF# of Class here) Control #_____________________

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FOR URS PERSONNEL ONLY

SENTENCES IN CAPITAL LETTERS ARE INSTRUCTIONS TO THE CLERK

AND ARE NOT INTENDED TO BE READ TO THE OWNER.

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. Please have your maintenance records in front of you for reference during the following 

questions. You should answer these questions to the best of your knowledge and indicate when you are not 

sure of something.

1. a. What is the engine family of your vehicle? The engine family can be found on a Vehicle Emission 

Control Information decal located underside of the hood. The engine family should start with: 

/ / Owner is unable to locate.

/ / Owner located. EF# ________________________________________

 

/ / Engine family located when vehicle arrived at the Lab.

ENGINE FAMILY 

Engine Family must be = (will be filled in by Task Officer)

b. What is the vehicle identification number? _______________________

c. What is the model of your vehicle? _________________ 

d. What kind of transmission does your vehicle have?: AUTOMATIC MANUAL OTHER

 If other, describe:_________________________________________________________

e. Is your vehicle air conditioned? YES NO 

f. What mileage is indicated on your odometer? ____________________

Has the odometer ever not functioned properly? YES NO 

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

CONSULT EPA FOR ELIGIBILITY IF THE RESPONSE IS "YES" to f.

2. Has your vehicle’s catalyst ever been replaced or removed?

YES / / NO / /

If yes, CALL EO.

3. a) Have you kept records of the maintenance and repairs performed on your vehicle?
(List Year, Make, EF# of Class here) Control #_____________________

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YES / / NO / /

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

Frequently, records 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 / /

4. EPA needs to share your maintenance records as well as this questionnaire and the test results with the 

manufacturer to correctly test the vehicle. Do you agree to this?

YES / / NO / /

 IF RECORDS ARE AVAILABLE, INFORM OWNER THAT: It is important that they are 

brought to the lab for review and duplication. 

5. Have you ever used any fuel other than that recommended by the manufacturer in your vehicle? 

YES / / NO / /

If Yes, what have you used? ___________________________________________________________

How often have you used it? ___________________________________________________________

When was the last time you used it?______________________________________________________

6. Has your vehicle: 

 

a) Been in an accident? YES / / NO / /

b) Had any engine repairs? YES / / NO / /

c) Any vehicle modifications? YES / / NO / /

If “yes” to any of the above, please describe: 

______________________________________________________________________________________

______________________________________________________________________________________

Has your vehicle had any: DATE:

d) Body work? YES / / NO / / ________________

e) Glass repair or replacement? YES / / NO / / ________________

f) Paintwork or detailing? YES / / NO / / ________________

g) Other? YES / / NO / / _________________

 

If “yes” to d – g above, please describe: 

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________
(List Year, Make, EF# of Class here) Control #_____________________

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IF “YES” TO ANY d) THROUGH f) ABOVE AND DATE IS LESS THAN 6 MONTHS FROM 

THE TIME OF THIS QUESTIONNAIRE, THIS VEHICLE SHOULD BE PUT ON HOLD.

g) New tires? YES / / NO / /

Date and mileage of the most recent tire installed? Date_________ Mileage___________

HAS IT BEEN LESS THAN 6 MONTHS AND/OR 6,000 MILES SINCE A TIRE 

REPLACEMENT? IF YES, THIS VEHICLE SHOULD BE PUT ON HOLD.

If a replacement part was installed, was it an original manufacturer part? Yes No

What was the approximate cost of the work done? 

Do you have any documentation of the work that was done? 

(NOTE TO URS: IF THE ANSWER TO ANY OF QUESTIONS a) THRU g) IS “YES”, 

PLEASE CONSULT WITH EPA STAFF BEFORE ACCEPTING THIS VEHICLE.)

7. Is your vehicle equipped with a trailer hitch ? Yes ____ No ____

Was the hitch installed by: dealer other

How much total weight has been hauled?: 

trailer + cargo = _____________________________________________

( IF YES, CONSULT WITH EPA STAFF BEFORE ACCEPTING THIS VEHICLE.)

INFORM THE OWNER THAT:

All valuables should be removed from the vehicle (including those in the glove box) prior to bringing 

the vehicle to the lab.