Pre/Post Intervention Survey Screener

Teen Safe Driving Measurement Research

Pre/Post Intervention Survey Screener

Qualified Respondents

- Parents of 15 to 18 year old teenage drivers

Test Markets Quotas

Pilot Market #1 900 screened, 400 participants

Pilot Market #2 900 screened, 400 participants

Name:	__________________________________________________________________
Address:	__________________________________________________________________
City:	________________________________ State:____________ Zip:_____________
Telephone:	(_______)_________________________________________________________

ASK TO SPEAK TO PERSON LISTED BASED ON RDD STANDARDS;
IF NOT AVAILABLE, MAKE APPOINTMENT TO CALLBACK

	Date	Time
Call Back 1	_____/_____/_____	____:____ am/pm
Call Back 2	_____/_____/_____	____:____ am/pm
Call Back 3	_____/_____/_____	____:____ am/pm

Main Introduction

Hello, my name is _______________ calling from ICR, a national research firm based in Pennsylvania. Today, we are conducting a brief study on behalf of the Centers for Disease Control and Prevention. The CDC is interested in the opinions of people from your area on issues that may affect you and your family. In particular, we would like to ask you some questions about teen driving. The interview will only take about eight minutes of your time and we are not selling anything.

If at any time and for any reason you would prefer not to answer any questions, please feel free not to. If at any time you would like to stop participating, please tell me. You will not be penalized in any way for deciding to stop participation at any time.

Public reporting burden for this collection of information is estimated to average 1 minute for the pre/post intervention survey screener per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920------).

A. I would like to speak to an adult 18 or older who lives in this household. If more than one adult is home now, may I speak with the person who had the most recent birthday?

1 Qualified adult is on phone GO TO Q.C

2 Qualified adult available ASK TO SPEAK WITH, REPEAT

MAIN INTRO AND GO TO Q.B

3 No adult is available now RESET TO DISPO SCREEN; SET-UP

CALLBACK

4 No adults 18+ living in household TERMINATE

R Refused TERMINATE

B. I would like to confirm that you are 18 or older. Is this correct?

1 Yes, is qualified adult CONTINUE

2 No, is not qualified RE-ASK Q.A

R Refused TERMINATE

C. How many children between the ages of 15 and 18 live in this household?

___________ (ENTER NUMBER)

00 None TERMINATE

RR Refused TERMINATE

(IF 1 IN Q.C, ASK:)

C1. Does this teenager have his or her driver’s license or learner’s permit?

1 Yes

2 No TERMINATE

R Refused TERMINATE

(IF 2+ IN Q.C, ASK:)

C2. How many of these teenagers have a driver’s license or learner’s permit?

___________ (ENTER NUMBER)

00 None TERMINATE

RR Refused TERMINATE

D. And are you the parent or guardian of (this teenager/these teenagers)?

1 Yes SKIP TO Q.F

2 No CONTINUE

R Refused TERMINATE

E. May I speak with a parent or guardian?

1 Qualified adult is on phone CONTINUE

2 Qualified adult available ASK TO SPEAK WITH, REPEAT

MAIN INTRO AND GO TO Q.F

3 No adult is available now RESET TO DISPO SCREEN; SET-UP

CALLBACK

4 No adults 18+ living in household TERMINATE

R Refused TERMINATE

F. RECORD GENDER OF RESPONDENT

1 Male

2 Female

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