NHTSA Form 1065 Interview Form Refueling

United States Department of Transportation National Highway Traffic Safety Administration

INTERVIEW FORM REFUELING (2/26/10 Draft)

Form Approved O.M.B. No. 2127-0626 Expiration Date: XXXX National Automotive Sampling System Tire Pressure Monitoring System – Special Study

1. Primary Sampling Unit Number ____ ____

2. Site Number ____ ____

3. Observation Number ____ ____

4. Date of Observation ____ ____/____/2010

5. Interview in: English Spanish

6. Observations: ( Interviewed Refused <2004)

   1. Body Type: Auto SUV Van PU

   2. Sex: Male Female

   3. Age: Young Adult Adult Senior

   4. Race: Indian Asian Black

Hispanic Hawaiian White

[Questions about Refueling]

7. How many miles did you drive to reach this destination? ____________________ (Nearest ¼ mile)

8. How much of that distance was out of your way to get to this gas station? ____________ (Nearest ¼ mile)

9. How much extra time did that take? ____________

(Code to nearest minute)

10. Before filling up your tank, where was the gas gauge? ________________ (Code to nearest 1/8^th tank)

11. How many persons total are in this vehicle? ______________________________________

12. How many of them are under the age of 16? _________________________________________

13. For each of the persons in this vehicle, what is his/her primary reason for traveling?

	Driver	Adults	<16 Yrs.
a. To/From Work
b. On Work Time
c. Personal
d. Shopping
e. Visiting
f. Leisure
g. Other

14. How many gallons of gas did you put in your vehicle? ___________________ (Code to nearest gallon)

15. After adding gas to your tank, where was the gas gauge? _____________ (Code to nearest 1/8^th tank)

16. If Full: Do you always fill up your tank?

If refueling, skip to #17

No Yes

17. Why did you stop for gas today? (Check one)

    1. Gas tank low

    2. Price of the gas

    3. Fill up on routine basis (e.g., weekly, bi-weekly)

    4. Top off tank for specific reason (e.g., before long trip)

    5. Convenient at this time

    6. Other (specify) _________________

18. Does this vehicle have a Tire Pressure Monitoring System – also known as a TPMS system?

    1. No

    2. Yes

    3. Don’t know

Now I need to ask you some basic information about yourself. [Demographic Information]

19. What is your home zip code? ___ ___ ___ ___ ___

20. How old are you? __________ (Code to nearest yr)

21. What is the highest grade or year of school you completed?

    1. Less than high school

    2. High school / GED

    3. Some college

    4. College graduate

    5. Higher degree

    6. (Vol) Refused

(Continue only for vehicles that have TPMS; Q#18)

22. Would you have time now to answer a few additional questions?

    1. No (Go to Q 23-Do Later)

    2. Yes (Go to Supplemental Form)

23. Would you be willing to answer a few additional questions at a later date, using:

    1. On-line

    2. Mail-back form

    3. Phone call back

    4. Refuse (End)

24. What is your name? ___________________________

25. At what phone number(s) would you like to be called? _______________________________________

26. What are good times to call? ___________________

27. SUP ID: _______________________

***Note: Check that INR14-INR16 have been answered***