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Study on the effects of coffe in driving

Do you have between 25 and 65 years? 

Do you want to participate in a study of the University Research Institute on Traffic and Road, driving in a car simulator and win 50 euros? 

You only have to come 3 afternoons from September, from 15:00 to 20:00 the days that we indicate you

If you are interested in collaborating with us and participating in this research, answer the following questions: 

Research questions: Study on the effects of coffee in driving

CONTACT DATA  (all fields are COMPULSORY)

1. Name

2. Email 

3. Contact telephone

4. Age  years

5. Gender

 Male 
 Female 

6.  Do you have driving license? 

 YES
NO

7. Specify which

Moped 
Motorcycle
Private car or similar
Heavi-duty vehicles 

8. How long do you have your driving license  years

9. Are you professional driver? 

 YES
NO

10. How often do you drive? 

Every or almost every day
Once a week 
Mainly weekends
Occassionally 

11.How many kilometres do you make at day when you drive km 

12.Do you work on shifts or in night shifts? 

 YES 
NO

13. Do you take any medicament? 

 YES
NO

Which?

14. Do you have coffee intolerance? 

 YES
NO

15 Do you have any sleep problem? 

 YES
NO

Which?

16.Do you take any medicament for sleeping? 

 YES
NO

Which?

17. Are you free on afternoons for making the research? 

SÍ
NO

 

According to the provisions of the Organic Law 15/1999, 13 December, on Personal Data Protection (LOPD), the person signing authorises to INTRAS the usage of the personal data contained in this application form for the study on the effects of coffee in driving.