Document ID: EPA-HQ-OAR-2010-0690-0004
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2011-02-22T05:00Z

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                                                           

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      Privacy Act Statement
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      Authority:  Title 42, United States Code Section 754
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      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.
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      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.
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      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.
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DATE OF CONTACT _______________________ TIME OF CONTACT  __________________

INDIVIDUAL CONTACTED_______________________________________________________

TO BE COMPLETED ___________________ DATE AND TIME OF COMPLETION___________

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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.

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? ______________________________________________

                                       
                                       
                                       

                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                            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?

   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:                                                                                                                                                                                                                                 ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
   
   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.