National Evaluation of a Mileage Based Road User Charge

National Evaluation of a Mileage-Based Road User Charge Recruitment Questionnaire

PAPERWORK BURDEN DISCLOSURE NOTICE

This collection of information is voluntary, and will be used to assess your acceptance of the National Evaluation of a Mileage-Based Road User Charge. Public reporting burden for this questionnaire is estimated to average 15 minutes. The burden estimate includes the time for reviewing instructions searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Your responses will be kept confidential to the extent permitted by law. The OMB control number for this collection is 2125-XXXX (state OMB #). Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Highway Administration, 400 Seventh Street, SW, Washington, DC 20590.

Thank you for completing the National Evaluation of a Mileage-Based Road User Charge questionnaire. Completing the following questionnaire does not assure your selection for the study. However, you cannot participate in the study unless you complete it.

Contact Information

Full Name:
First						Last			M.I.
Address:
Street Address									Apartment/Unit #
City								State	ZIP Code
Home Phone:			( )		Alternate Phone:		( )
E-mail Address:

Item #	National Evaluation of a Mileage-Based Road User Charge Questionnaire
1	What county do you live in?	1			______________________________
2	Do you have a valid driver’s license?	1			Yes
		2			No
3	What is your date of birth?	_________ (year) ______ (month) _______ (day)
4	Are you a U.S. citizen?	1			Yes
		2			No
5	Do you own a personal vehicle?	1			Yes
		2			No
6	Is your vehicle currently insured?	1			Yes
		2			No
7	Are you planning on relocating in the next 12 months?	1			Yes
		2			No
8	What is the make of your vehicle?	1			____________________________________
9	What is the model of your vehicle?	1			____________________________________
10	What is the year of your vehicle?	1			____________________________________
The following questions apply to you. Please select an answer from the list to the right of the question.
11	Are you Spanish, Hispanic, or Latino origin?		1	Yes
			2	No
12	Which of the following races do you consider yourself to be? Select all that apply.		1	White
			2	Black or African American
			3	American Indian and Alaska Native
			4	Asian
			5	Native Hawaiian or other Pacific Islander
13	What is the preferred language spoken in your household?		1	English
			2	Spanish
			3	Other (please specify)
14	What is your sex?		1	Female
			2	Male
15	From the following list what is the highest degree or level of school you have completed?		1	Did not complete high school
			2	Completed high school or equivalency
			3	Completed some college/earned an associate’s degree
			4	Earned bachelor’s degree or higher
16	Are you currently a student?		1	Yes
			2	No
17	Are you employed outside of the home?		1	Yes
			2	No
18	If employed, which of the following categories best describes your occupation?		1	Professional, technical and related
			2	Administrative & management
			3	Clerical and related
			4	Sales
			5	Homemaker
			6	Service
			7	Agriculture, forestry or fishermen
			8	Production & related
			9	Other______________________
19	What is your household income in the past 12 months?		1	<$4,999
			2	$5,000 - $24,999
			3	$25,000 - $74,999
			4	$75,000 or more

The following questions refer to your driving behaviors. Please select ONLY one answer from the list to the right of the question.
20		What is your approximate travel time to work?		1		Less than 10 minutes
				2		10 to 14 minutes
				3		15 to 19 minutes
				4		20 to 24 minutes
				5		25 to 29 minutes
				6		30 to 34 minutes
				7		35 to 44 minutes
				8		45 to 59 minutes
				9		60 or more minutes
The following questions will assess your attitude on various topics. Please select ONLY one answer from the list to the right of the question.
21	We hear a lot of talk these days about liberal and conservatives. On the right is a scale which is commonly used to determine political views that people might hold or share. Where would you place yourself on this scale?		1		Extremely liberal
			2		Liberal
			3		Slightly liberal
			4		Moderate, middle of the road
			5		Slightly conservative
			6		Conservative
			7		Extremely conservative
			8		Don’t know
22	If the federal government had a choice between reducing the gas tax, continuing with the current gas tax or raising the gas tax in order to maintain roadways, which do you think it should do?		1		Reduce gas taxes
			2		Continue with current gas tax
			3		Raise gas tax
			8		Don’t know
23	Are we spending too little money, about the right amount of money, or too much money on improving the condition of highways and bridges?		1		Too little
			2		About right
			3		Too much
			8		Don’t know
24	Often people report that they’re not exactly sure what the combined federal and state gas tax per-gallon is. What do you think the combined federal and state gas tax is in your state?		1		___________________ (Format: $0.00)

Thank you! Please return the survey in the self-addressed postage paid envelope that was provided.

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Pre- and Full-Screening Survey-Mailed Version