Form NHTSA Form 1084 NHTSA Form 1084 Distracted Driving Intercept Survey

OMB # XXXX-XXXX Expiration Date: [Month] 31, 2012

Appendix E - DMV Office Community Intercept Survey

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2127-XXXX. Public reporting for this collection of information is estimated to be approximately 10 minutes per response including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. 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, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

DMV Survey Administrator Screening Questionnaire

Note to survey administrator: Refer to your instruction for selecting participants to approach, and which if any demographic groups are no longer being sought for this data collection effort.

Hello, I'm __________________ distributing surveys for the U.S. Department of Transportation. We are conducting a study of Americans' driving habits and attitudes.

I have a few quick questions to ask you, and this part of the study will only take 1 minute of your time.

This collection of information is Voluntary and will be used for statistical purposes only so that we may develop and evaluate programs designed to reduce the number of traffic-related injuries and deaths. Public reporting burden is estimated to average 1 minute 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. Your participation is anonymous, and we will not collect any personal information that would allow anyone to identify you. Please note that a federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number. The OMB control number for this collection is 2125-XXXX.

Could we begin now?

IS.1) Thank you. First, can I ask which age group best describes you?

1. 16-18

2. 18-20

3. 21-34

4. 35-49

5. 50-59

6. 60 +

IS.2) Do you consider yourself Hispanic or Latino?

1. Yes

2. No

IS.3) Which of the following racial categories describes you? You may select more than one.

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or other Pacific Islander

5. White

IS.4) FROM OBSERVATION, NOTE SEX OF RESPONDENT

1. Male

2. Female

IS.5) [IF NORWALK CT SAMPLE ASK] Do you reside in Stamford?

1. Yes

2. No

IF UNFULFILLED QUOTA – I now have a brief survey for you to complete while you wait for your license. Would you mind completing the survey and dropping it in the box over there [indicate where to drop surveys]

IF FULFILLED QUOTA – Thank you so much for your time, have a good day.

DMV Intercept Survey

Several Driver Licensing Offices are participating in a study about distracted and unsafe driving in [STATE]. Your answers to the following questions are voluntary and anonymous. Please complete the survey and drop it in the box.

This collection of information is voluntary and will be used for statistical purposes only so that we may develop and evaluate programs designed to reduce the number of traffic-related injuries and deaths. Public reporting burden is estimated to average 10 minutes 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. Your participation is anonymous, and we will not collect any personal information that would allow anyone to identify you. Please note that a federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number. The OMB control number for this collection is 2125-XXXX.

1. Your sex: [] Male [] Female

2. Your age: [] Under 18 [] 18-20 [] 21-34 [] 35-49 [] 50-59 [] 60 Plus

3. Do you consider yourself Hispanic or Latino? [] Yes [] No

4. Your race: Check all that apply: [] American Indian or Alaska Native [] Asian [] Black or African American

[] Native Hawaiian or other Pacific Islander [] White

5. Your Zip Code: _______________________

6. About how many miles did you drive last year?

[] Less than 5,000 [] 5,000 to 10,000 [] 10,001 to 15,000 [] More than 15,000

7. What type of vehicle do you drive most often?

[] Passenger car [] Pickup truck [] Sport utility vehicle [] Mini-van [] Full-van [] Other

8. How often do you talk on a hand-held cellular phone when you drive?

[] Always [] Nearly always [] Sometimes [] Seldom [] Never

9. How often do you send text messages or emails on a hand-held cellular phone when you drive?

[] Always [] Nearly always [] Sometimes [] Seldom [] Never

10. Do you think that it is important for police to enforce hand-held cellular phone laws? [] Yes [] No

11. What do you think the chances are of getting a ticket if you use a hand-held cellular phone while driving?

[] Always [] Nearly Always [] Sometimes [] Seldom [] Never

12. Do you think the hand-held cellular phone law in [STATE] is enforced:

[] Very strictly [] Somewhat strictly [] Not very strictly [] Rarely [] Not at all

13. Have you EVER received a ticket for using a hand-held cellular phone while driving? [] Yes [] No

14. In the PAST MONTH, have you received a ticket for using a hand-held cellular phone while driving?

[] Yes [] No

15. In the PAST MONTH, have you seen or heard about police enforcement focused on hand-held cellular phone use?

[] Yes [] No

16. Have you recently read, seen or heard any messages about the enforcement of hand-held cellular phone laws in [STATE]?

[] Yes [] No

If yes, where did you see or hear about it? (Check all that apply):

[] Newspaper [] Radio [] TV [] Billboards [] Brochure [] Online [] Police Enforcement [] Other

If yes, what did it say? ___________________________________________________________

17. Do you know the name of any distracted driving program(s) in [STATE]? (check all that apply):

[] Slogan #1 [] Slogan #2 [] Slogan #3 [] Slogan #4

NHTSA Form 1084 3 of 3