
										OMB No. 2060-0086
                             								Expires ###		
TELEPHONE SCREENING TOOL	                                                                                                                                                      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 ____________________________________________________

                             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.














DATE OF CONTACT _____________________ TIME OF CONTACT _____________________________

INDIVIDUAL CONTACTED _______________________________________________________________

TO BE COMPLETED _____________________ DATE AND TIME OF COMPLETION _______________

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The public reporting and recordkeeping burden for this collection of information is estimated to average
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20 minutes per response. Send comments on the Agency's need for this information, the accuracy of the
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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 PAGEHAS 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)

      
   
   
    
   
   
   
   
   
