Drink & Simulator Driving Test – Entry Form Name Email Phone number (without haiphong) (P1) Gender 1. Male2. Female (P2) Age (P3) Prefecture where you live 25. Shiga26. Kyoto27. Osaka28. Hyogo29. Nara30.Wakayama31. Other (P3-1) City (or town) where you live (FS0) Please select all industries from the below in which you and your household members work. 1. Manufacturing (Food/Beverage)2. Manufacturing (Pharmaceuticals/Cosmetics/Chemicals/Daily Necessities)3. Manufacturing (AV/Home Appliances/Electrical machinery)4. Manufacturing (Automobile related industry)5. Manufacturing (Others)6. Wholesale/Retail (Food/Beverage)7. Wholesale/Retail (Pharmaceuticals/Cosmetics/Daily Necessities)8. Wholesale/Retail (AV/Electronics/Electrical machinery)9. Wholesale/Retail (automobile-related)10. Wholesale/Retail (department stores/supermarkets/convenience stores)11. Wholesale/Retail (others)12. Transportation/Transportation13. Communication/information processing service14. Hotel15. Restaurant16. Real estate17. Finance18. Electricity, gas and water19. Publishing/Printing industry20. Media-related industry21. Research industry, advertising agency business, marketing industry22. None of the above industries are engaged (FS1) Country of origin (FS2) Race 1. African2. Arabian3. Asian4. Caucasian5. Hispanic6. Indian7. Other (FS3) Your Japanese speaking skill 1. Can speak both daily and business conversation2. Can speak daily conversation3. Can speak simple conversation4. Can say greetings5. Can't speak any Japanese at all (FS4) Your Japanese reading skills (select all that apply) 1. Can read hiragana2. Can read katakana3. Can read kanji4. Can't read at all (FS5) Occupation 1. Manager/company executive2. Company employee3. Public employee4. Temporary/contract employee5. Specialist (doctor, lawyer, accountant, etc.)6. Self-employed7. Freelance8. Part-time job9. Employees on maternity/childcare leave10. Student11. Housework12. Housewife/Househusband13. Unemployed14.Others (FS6-1) Type of business of the company you work for (e.g. school, trading company, IT company etc.) (FS6-2) Job description (e.g. teaching English, developing systems, studying etc) (Q1-1) Height (cm) (Q1-2) Weight (Kg) (Q2)Do you have a driving licence? 1. Have a Japanese driver's licence2. Have a driver's licence from a country other than Japan3.I do not have a driver's licence from any country. (Q3) If you have a driver’s licence, have you driven since obtaining it? 1.Never driven since I got it.2. I have drives since I got it. (Q4) Please choose a color that is closer to your skin tone from the more detailed color chart below than in the previous question. (Q5) Please select all the types of alcohol you usually drink 1. Beer2. Happoshu(Low-malt beer3. Japanese Sake4. Shochu5. Wine6. Whisky7. Chu-Hi and sours8. Fruit liqueurs and cocktails9. Plum wine10. Highballs11. Non-Alcoholic drinks12. Other13. Do not drink (Q6) On average, how much alcohol (in ㎖(milliliters)) do you usually drink?(cf Standard beer can size: 350 ml) ml (Q7) Can you drink a lot? 1. Yes, I can drink a lot.2. Yes, I can drink moderately.3. Yes, I can drink.4. I can't drink much.5. I can hardly drink at all. (Q8) Do you usually wear glasses or contact lenses? (If you wear glasses and contact lenses on a case-by-case basis, choose both.) 1. Glasses2. Contact lenses3. Neither (Q10-1) The test procedures are as follows. Can you agree? ①You will drink alcohol on the test day. (The amount of alcohol you drink depends on your weight *e.g. 100 ml x 3 times for a person weighing 60 kg. You can choose from sake, wine(red or white), or whisky (about 15% alcohol content)) ②After drinking, you will take a test on a driving simulator (approx. 1 hour).③You will take a break to sober up at the venue before leaving (approx. 30 min). Can you agree? 1. Agree2. Disagree (Q10-2) During the test, stickers will be placed on your skin in 3 portions for data collection: the right and left collarbones and the left ribs. Can you agree? 1. Agree2. Disagree (Q10-3) Can you agree to the followings? – Will not take the test wearing glasses, but with naked eyes or contact lenses. – Will not drive yourself to the venue as you will be drinking alcohol on the day. 1. Agree2. Disagree (Q11) Which alcohol you would like to drink on the test day? 1. Sake2. Red wine3. White wine4. Whisky (Q12) Do you have interest in taking the following additional test? (If you are selected to take this test, you will receive an additional ¥5,000) Genetic test for alcohol sensitivity: https://www.dnakensa.com/kit/alcohol.html * On the day of the test, you will put the tip of the swab in your mouth and rub the side of your inside cheek to collect samples, which will be sent to the test center directly by post. *The results will be sent directly only to you by email. *You will only inform us your ‘alcohol type’ in the results. We do not need any other personal information from you. *No testing fees are required (to be paid by the client). *We will decide which of those who wish to participate will be asked to take the test. 1 Yes I have interest2 No I don’t. (Q13) On the day of the test, you will be asked to show your ID. Choose an ID you will present from the followings:(Credit cards, loyalty cards, membership cards and Tapo cards are not accepted.Photocopies are not accepted. Original documents only.) 1. Driver's license2. My number card3. Passport4. Health insurance card5. Student ID card with photo6. Others7. None (Q14) Participants are asked to remove their masks while driving for data measurement. (Experimenters will wear masks.) Do you agree? 1. Yes Agree2. Disagree (Q15) As for the health conditions, do you agree to all of the following? If you have a fever of 37.2 degrees Celsius or higher from the day before or on the study day, you may not be able to participate in the study. You may be asked to take your temperature at the study venue. You may be asked to disinfect your hands with alcohol or hypochlorite water before entering the venue. You may be asked to wear medical gloves. (Please answer “Disagree” if you are allergic to rubber.) We are aware that your participation in this study is at your own risk, although we are making every effort to provide a safe environment for all the participants. Even if you are infected with COVID-19 in connection with this participation, the client and our company are not responsible for it. 1. Yes, I all agree2. Disagree (Final) Please upload your face photo here: Δ