CROPS Demonstrators Pretest

APPENDIX C.1a – CROPS Demonstrators Pretest

Form Approved

OMB No. 0920-09CO

Exp. Date xx/xx/20xx

CROPS Demonstrator Pretest⁰

NIOSH researchers who are making this program possible would like the following information. Type, size of operation and income information are needed so comparison with other farmers in the state can be made. Your participation in these questions is voluntary and will not affect your ability to participate in the program.

Name _______________________________________

Address _____________________________________

_____________________________________

City _________________________, zip code ________________

Type of tractor you own that you would like retrofitted:

year _______, make ________, model ____________

(Ford 3000, 4000, 4600, Ford 8N, Massey Ferguson 135)

Why have you not retrofitted the above tractor with a ROPS? (Please rank the selections as 1=most important, 7=least important)

Cost too much_____ Too much hassle to find one_____ ROPS not available_____

Not that important_____ Not enough time to find one_____ Dealer not helpful_____

Other (please explain)_____ _____________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

How important do you believe it is to have roll over protection on your tractor(s)? (circle your answer)

“not at all important” “not very important” “important” “very important”

Why do you believe rollover protection is (your answer above)? _______________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

In the following question we would like you to rate the statements given on a scale of 1 to 10. For example, Installing a roll-over protective structure on my unprotected tractor is…. Bad farm practice/good farm practice, 1 being bad, 10 being good

Installing a roll-over protective structure on at least one of my unprotected tractors is…

bad farm practice 1 2 3 4 5 6 7 8 9 10 good farm practice

not cost effective 1 2 3 4 5 6 7 8 9 10 very cost effective

inconvenient 1 2 3 4 5 6 7 8 9 10 convenient

unnecessary 1 2 3 4 5 6 7 8 9 10 necessary

irresponsible 1 2 3 4 5 6 7 8 9 10 responsible

Please indicate how you feel about the following statements, circling your desired response

It is less likely that anyone on my farm would be killed or hurt in a tractor roll-over, when compared to other farms.

Strongly Disagree Disagree Agree Strongly Agree

Most people who are important to me think that I should retrofit at least one of my unprotected tractors.

Strongly Disagree Disagree Agree Strongly Agree

It is expected of me that I retrofit at least one of my unprotected tractors.

Strongly Disagree Disagree Agree Strongly Agree

I feel pressured to retrofit at least one of my unprotected tractors.

Strongly Disagree Disagree Agree Strongly Agree

If I have a ROPS/CROPS on my tractor, I will wear my seatbelt whenever I am on the tractor.

Strongly Disagree Disagree Agree Strongly Agree

How many other tractors do you own/use? _______

How many of these have an approved roll over protective structure (ROPS), such as a roll-bar or cab? (Tractor has a plaque in the cab or on the ROPS which states structure is ASAE approved.) _______

Please list the make and model of tractors you own/use with estimated annual hours of operation and whether they are equipped with a ROPS or ROPS cab:

Tractor 1 make/model__________ hours operation/year_______ ROPS: Yes No

Tractor 2 make/model__________ hours operation/year_______ ROPS: Yes No

Tractor 3 make/model__________ hours operation/year_______ ROPS: Yes No

Tractor 4 make/model__________ hours operation/year_______ ROPS: Yes No

Gender (circle): Male Female

Age: _________ years

Do you have children (18 or under) on the farm operating a tractor? Yes _____ No _____

What age(s)? ________________________________________________________

Type of Farm (check): Crop _____ Livestock _____ Crop & Livestock _____

Dairy _____ Other____ (please list type) ___________________

Size of farm: _______ acres

Gross sales of farm (check which applies):

____ <$2500

____ $2500 - $4999

____ $5,000 - $9,999

____ $10,000 – $24,999

____ $25,000 - $49,999

____ $50,000 - $99,999

____ $100,000 - $299,999

____ $300,000 - $499,999

____ >$500,000

Number of days you work off farm in a year (check which applies): _____ None

_____ Any

_____More than 200 days

Total gross family income: $__________________

OR

Percent that farm income is for total gross family income__________%

If you would like a copy of the survey results mailed to you, please place a check mark

here _____ . We will use the mailing address you listed at the beginning of the survey, unless you want us to use a different one, which you may list below.

Alternate mailing address:

Name _________________________________________________________

Address _______________________________________________________

City­­­­­­­­­­­­­­­­­­­____________________ State____ Zip_______________

Thank you for your participation in our study to help make farming safer.

0 Public reporting burden of this collection of information is estimated to average 15 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. 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-09CO).