										OMB No. 2060-0086 expires (##)

									

TELEPHONE QUESTIONNAIRE	                                                
                                                                        
                            FOR CONFIRMATORY CLASS:   

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 ____________________________________________________

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

provided 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 Pennsylvania Ave., NW,
Washington, DC, 20460.  Include the OMB control number in any
correspondence.  Do not send the completed form to this address.

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 incentive 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 incentive 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 Security 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.



FOR “JACOBS PERSONNEL” ONLY

SENTENCES IN CAPITAL LETTERS ARE INSTRUCTIONS TO THE CLERK

AND ARE NOT INTENDED TO BE READ TO THE OWNER.

a.  What are 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 with the letters  ___.

	/    / Owner is unable to locate.

	/    / Owner located.  TEST GROUP __________________

ELIMINATE IF TEST GROUP IS NOT ___

          

b. MODEL ____________________ VEHICLE ID NO. ________________________

	MODEL YEAR _________

	TRANSMISSION:   AUTOMATIC /    /  AIR 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 ELIGIBILITY 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 purchase?

		YES/    /       NO/    /       DO NOT 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.

Are you the original purchaser or lessee of the vehicle?

YES/    /      NO/    /

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

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

   	IF NO, ELIMINATE.

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

(REGULARLY REQUIRED STATE 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 delivery vehicle?   
 	 	____		____

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

7.  Have you ever used your vehicle to plow snow?			 	_____		_____

	ELIMINATE IF “YES” TO ANY POSITIVE RESPONSE 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 _________ POUNDS

 Have any non-factory parts or special devices been installed on your
vehicle?  If yes, what are the brands 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		____	
____________________

other (describe) 

	_____________________________________________________________________

	_____________________________________________________________________

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


Cap, toolbox, 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.

 a. Have you ever used any fuel other than that recommended by the
manufacturer in your vehicle?  (ex. Diesel fuel, E85) YES /  /   NO /  /

		If Yes, Eliminate

b. Have you ever used fuel system additives?

		    YES/    /       NO/    /

		     If Yes, what have you used and
why?________________________________________

		     How often have you used it?
______________________________________________

		     When was the last time you used it?
________________________________________

		        IF “YES”, CONSULT EPA FOR ELIGIBILITY.

 Has the catalytic converter been removed or replaced?

YES/   /     NO/   /     DON’T KNOW /   /

IF YES ELIMINATE

 Have any emission control system components been altered, modified or
disconnected?  This does not include repairs or maintenance.	YES/   /   
 NO/   /

	IF YES, ELIMINATE.

 Has your vehicle ever overheated?  YES/   /     NO/   /

	STOP QUESTIONNAIRE AND ELIMINATE IF VEHICLE HAS OVERHEATED             
         

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
System…………………………………………………….
_____	_____

	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.

      
________________________________________________________________________
________________

           
________________________________________________________________________
________________

IF 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 been repaired?

YES/    /     NO/    /

e.   If yes; what, when, by whom and at what cost?

    	 What
_______________________________________________________________

     	When
_______________________________________________________________

    	 Who
________________________________________________________________

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, go 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 EPA FOR
ELIGIBILITY.

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 MISSED

 Do 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 correct a
problem) been performed on your vehicle in the following areas?		

							YES		NO 

		Engine					_____		_____

		Fuel injection				_____		_____

		Transmission, drive shaft, axle	_____		_____

		Exhaust system			_____		_____

		Ignition system/Electrical system	_____		_____

		Cooling system			_____		_____

		Fuel tank				_____		_____

		Emission control system		_____		_____

		Oxygen Sensor			_____		_____

		Computerized engine system		_____		_____

		Other					_____		_____

	b. If the answer to any of the above items is yes, please describe
what, why, when, and 			where.

		WHAT _______________________________________________________

		WHY _________________________________________________________

		WHEN (Date and mileage)_________________________________________

		WHERE _______________________________________________________

		WHAT _______________________________________________________

		WHY _________________________________________________________

		WHEN (Date and mileage)_________________________________________

		WHERE _______________________________________________________

		

		

WHAT _______________________________________________________

		WHY _________________________________________________________

		WHEN (Date and mileage)_________________________________________

		WHERE _______________________________________________________

	CONSULT EPA FOR ELIGIBILITY IF QUESTION (b) IS ANSWERED

19. a. Have you had any performance or drivability problems with your
vehicle?  

   YES /    /     NO /    /

   IF NO, GO TO NEXT NUMBERED QUESTION.

   If yes, describe:
________________________________________________________

   _____________________________________________________________________

b. Would the problems you described fall into any of the following
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 problems.
____________________________________________________

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

		WHAT _______________________________________________________

		WHEN (Date and mileage)_________________________________________

		WHERE _______________________________________________________

		WHAT _______________________________________________________

		WHEN (Date and mileage)_________________________________________

		WHERE _______________________________________________________

d. How long 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.

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

NO /   /     YES /    /   approximate date __________________

21. a. Describe the recall or give the recall number
_______________________

________________________________________________________________________
_____________________

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

	YES /    /    NO /    /                   

22. 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 /  /

 If “yes”  is important that the records are brought to 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, 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 /  /

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 get from your house to Ann Arbor.

     

STOP QUESTIONNAIRE FOR CLASS T005/T006

26.   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.

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

28.  Have any of the windows been replaced/repaired?   If yes, state how
long ago? _______

29.  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?____

31.  Is the vehicle equipped with any interior or exterior modifications
such as upholstery or a vinyl roof which were not factory installed?  If
yes, how long ago?

32.  Has the vehicle been washed with a non-was detergent? 

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. 

COMMENTS:_______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
__________________________________________________ 



Information Update Page

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?

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 did it happen (include odometer reading)?

How does it affect the vehicle now?

_________________________________________                           
______________________________

Participant Signature                                   Date            
                    Jacob’s Representative		Date

2011 GM BGMXVO1.8011

Control No.  T005/T006  RXXC- _________

VIN _______________________________

State of ________________________________ County of
_____________________________

I,
________________________________________________________________________
___,

being 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 knowledge
of all matters    discussed herein.  I have read the responses to the
questions stated above, and such responses are true 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)

 

Class #   MY Manufacturer Name  Model Name   Test Group                 
            ClassRXXC- _______

EPA Form 5900-308 (Revised 1/17/2014)  			Page   PAGE   \* MERGEFORMAT 
1 

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 primary 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, including 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 approve your participation in the
Light-Duty In-Use Testing Program.

