NHTSA Form 1055B
MDAC/ABT SRBI, INC. STUDY NUMBER P1724/4304c
April 15, 2010
OMB No. 2127-0663
Expiration Date: 11/30/2012
SURVEY ON UNREPORTED CRASHES (Landline)
SAMPLE READ‑IN
STATE
COUNTY (FIPS CODE)
METRO STATUS
Date: ________________ CATI ID: ____________________
Interviewer:_________________________________________
Telephone Number: __________________________________________________________
Time Start: _____________ Time End: _____________ TOTAL TIME: ___________
____________________________________________________________________________
LANDLINE SAMPLE
INTRODUCTION
Hello, I'm __________________ from M. Davis and Company calling for the U.S. Department of Transportation. We are conducting a national study of Americans' driving habits. (If you would like to learn more about the survey, you can call our toll-free number at [MDAC CATI: 1-800-842-4836] [ABT SRBI CATI: 1-888-772-4269] or call Jonathan Walker at 1-202-366-8571).
Paperwork Reduction Act Burden Statement [READ ONLY IF ASKED]
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 2127-0663, with an Expiration Date of 11/30/2012. Public reporting for this collection of information is estimated to be approximately 15 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, NHTSA, 1200 New Jersey Ave SE, Washington, D.C. 20590.
DUMMY QUESTION FOR BIRTHDAY QUESTIONS (COMPUTERIZED RANDOM SELECTION)
Has had the most recent.......1
Will have the next................2
A1. How many persons, age 16 and older, live in this household?
______ Number of 16+ persons (7=7or more)
(VOL) None........THANK AND SCREEN OUT
Refused…………………….….9 THANK AND END, [HARD/SOFT REFUSAL]
IF A1>=1, QUAL 1
A2. IF A1 = 1 READ "May I please speak to him or her?"
If A1 >1 READ "In order to select just one person to interview, may I please speak to the person in your household, age 16 or older, who (has had the most recent/will have the next) birthday?"
Designated Respondent on line........…1 GO TO C
Someone else................................….2 GO TO B
SCHEDULE CALLBACK..........…..3
Refused…………………............….4 THANK AND END, [HARD/SOFT REFUSAL]
IF A2=1 OR A2=2, QUAL 2
B. Hello, I'm _______________ from M. Davis and Company calling for the U.S. Department of Transportation. We are conducting a national study of Americans' driving habits and their attitudes about current driving laws. (If you would like to learn more about the survey, you can call our toll-free number at 1-800-842-4836 or call Jonathan Walker at 1-202-366-8571)
C. The interview is voluntary and the information you provide us will be used for statistical purposes only. We will not collect any personal information that would allow anyone to identify you. If there is a question you don’t want to answer, that’s OK. The interview takes about 15 minutes to complete. (This study has been reviewed and approved by the Office of Management and Budget under OMB control number 2127-0663.) Could we begin now?
CONTINUE INTERVIEW................1 SKIP TO D
Arrange Callback.................................2
Want to think about it/Not sure…..….3 CALLBACK
Refused................……………….........4 THANK AND END, [HARD/SOFT REFUSAL]
D. INTERVIEWER RECORD RESPONDENT GENDER [ASK ONLY IF NECESSARY]
Male………..1
Female………2
INITIALIZE CRASH FLAGS
IN1=0
IN2=0
IN3=0
DM1=0
INITIALIZE REPORT FLAG
REPCRSH=0
CRASH EXPERIENCE
Q1. How often do you drive a motor vehicle? Everyday or almost every day, a few days a week, a few days a month, a few days a year, or do you never drive?
Almost every day/every day..........………1
Few days a week.....................................2
Few days a month...........…...........……...3
Few days a year......................................4
Never..........................................……....5
(VOL) More than a year ago..............…6
(VOL) Other (Specify)……….………..7
(VOL) Don't know................................8
(VOL) Refused............................…….9
QUAL 3
Q2a. Have YOU ever been INJURED in a motor vehicle accident in which you were a DRIVER?
Yes......................................1
No.......................................2 SKIP TO Q3a
(VOL) Don't know............…8 SKIP TO Q3a
(VOL) Refused....................9 SKIP TO Q3a
Q2b. When was the most recent time this happened (injured as a driver)? Was it ….
Less than 6 months ago .……………………………1 IN1=1
Six months ago but less than 12 months ago ………2 IN1=1
12 months ago but less than 2 years ……………….3 SKIP TO Q3a
2 years ago but less than 4 years ……….………….4 SKIP TO Q3a
Four or more years ago……………………….……5 SKIP TO Q3a
(VOL) Don’t Know….……………………….……8 SKIP TO Q3a
(VOL) Refused……………………………….……9 SKIP TO Q3a
Q2c. How many times has this happened to you in the past 12 months?
_____________________ TIMES RANGE=1-7
DON'T KNOW=8 REFUSED=9
LOOP FOR EACH INCIDENT IN Q2c [MAX 4 LOOPS even though 2c accepts up to 7 motor vehicle crash injuries]
Q2d. In what month(s) did the (most recent/next most recent) crash occur?
1 December 2008
2 January 2009
3 February 2009
4 March 2009
5 April 2009
6 May 2009
7 June 2009
8 July 2009
9 August 2009
10 September 2009
11 October 2009
12 November 2009
13 December 2009
14 January 2010
15 February 2010
16 March 2010
17 April 2010
18 May 2010
98 (VOL) Don’t Know
99 (VOL) Refused
Q2e. In what state did the (most recent/next most recent) accident occur?
(ENTER TWO-LETTER STATE DESIGNATION)
Q2f. Was anyone else injured in (that/the next) accident where you were a driver? (Include ALL people, such as injured pedestrians, bicyclists, or people in ANY vehicle involved.)
Yes…………….…….1
No……………………2 SKIP TO Q3a
(VOL) Don’t Know….8 SKIP TO Q3a
(VOL) Refused………9 SKIP TO Q3a
Q2g. How many other people were injured in that crash?
NUMBER: ___________
97=97 or more
98 Don’t Know
99 Refused
GO TO NEXT LOOP (Q2d) UP TO FOUR LOOPS
Q3a. Have YOU ever been INJURED in a motor vehicle accident when you were a PASSENGER?
Yes......................................1
No.......................................2 SKIP TO Q4a
(VOL) Don't know..........…..8 SKIP TO Q4a
(VOL) Refused....................9 SKIP TO Q4a
Q3b. When was the most recent time this happened (injured as a passenger)? Was it ….
READ LIST
Less than 6 months ago .………………………..…..1 IN2=1
Six months ago but less than 12 months ago ………2 IN2=1
12 months ago but less than 2 years ………….……3 SKIP TO Q4a
2 years ago but less than 4 years ………..…………4 SKIP TO Q4a
Four or more years ago………………………..…...5 SKIP TO Q4a
(VOL) Don’t Know….……………………….……8 SKIP TO Q4a
(VOL) Refused……………………………….……9 SKIP TO Q4a
Q3c. How many times has this happened to you in the past 12 months?
_____________________ TIMES RANGE=1-7
DON'T KNOW=8 REFUSED=9
LOOP FOR EACH INCIDENT IN Q3c [MAX 4 LOOPS] even though 3c accepts up to 7 motor vehicle crash injuries]
Q3d. In what month(s) did the (most recent/next most recent) crash occur?
1 December 2008
2 January 2009
3 February 2009
4 March 2009
5 April 2009
6 May 2009
7 June 2009
8 July 2009
9 August 2009
10 September 2009
11 October 2009
12 November 2009
13 December 2009
14 January 2010
15 February 2010
16 March 2010
17 April 2010
18 May 2010
98 (VOL) Don’t Know
99 (VOL) Refused
Q3e. In what state did the (most recent/next most recent) accident occur?
(ENTER TWO-LETTER STATE DESIGNATION)
Q3f. Was anyone else injured in (that/the next) accident where you were a passenger? (Include ALL people, such as injured pedestrians, bicyclists, or people in ANY vehicle involved.)
Yes…………….…….1
No……………………2 SKIP TO Q4a
(VOL) Don’t Know….8 SKIP TO Q4a
(VOL) Refused………9 SKIP TO Q4a
Q3g. How many other people were injured?
NUMBER: ___________
97=97 or more
98 Don’t Know
99 Refused
GO TO NEXT LOOP (Q3d) UP TO FOUR LOOPS
Q4a. Have YOU ever been hit by a motor vehicle and INJURED when you were a pedestrian, that is, not traveling in a motor vehicle at the time of the accident?
Yes......................................1
No.......................................2 SKIP TO Q5a
(VOL) Don't know.........…...8 SKIP TO Q5a
(VOL) Refused....................9 SKIP TO Q5a
Q4b. When was the most recent time this happened (injured as a pedestrian)? Was it
READ LIST
Less than 6 months ago ……………………...……..1 IN3=1
Six months ago but less than 12 months ago ………2 IN3=1
12 months ago but less than 2 years ……………….3 SKIP TO Q5a
2 years ago but less than 4 years ……….………….4 SKIP TO Q5a
Four or more years ago…………………………….5 SKIP TO Q5a
(VOL) Don’t Know….……………………….……8 SKIP TO Q5a
(VOL) Refused……………………………….……9 SKIP TO Q5a
Q4c. How many times has this happened to you in the past 12 months?
_____________________ TIMES RANGE=1-7
DON'T KNOW=8 REFUSED=9
LOOP FOR EACH INCIDENT IN Q4c [MAX 4 LOOPS] even though 4c accepts up to 7 motor vehicle crash injuries]
Q4d. In what month(s) did the (most recent/next most recent) crash occur?
1 December 2008
2 January 2009
3 February 2009
4 March 2009
5 April 2009
6 May 2009
7 June 2009
8 July 2009
9 August 2009
10 September 2009
11 October 2009
12 November 2009
13 December 2009
14 January 2010
15 February 2010
16 March 2010
17 April 2010
18 May 2010
98 (VOL) Don’t Know
99 (VOL) Refused
Q4e. In what state did the (most recent/next most recent) accident occur?
(ENTER TWO-LETTER STATE DESIGNATION)
Q4f. Was anyone else injured in (that/the next) accident? (Include ALL people, such as injured pedestrians, bicyclists, or people in ANY vehicle involved.)
Yes…………….…….1
No…………………….2 SKIP TO Q5a
(VOL) Don’t Know…..8 SKIP TO Q5a
(VOL) Refused……….9 SKIP TO Q5a
Q4g. How many other people were injured?
NUMBER: ___________
97=97 or more
98 Don’t Know
99 Refused
GO TO NEXT LOOP (Q4d) UP TO FOUR LOOPS
SKIP TO 7a IF IN1=1 OR IN2=1 OR IN3=1
Q5a. Have you ever been in a motor vehicle accident in which THE VEHICLE YOU WERE IN was damaged?
Yes......................................1
No.......................................2 SKIP TO direction before Q6
(VOL) Don't know........…....8 SKIP TO direction before Q6
(VOL) Refused..............…...9 SKIP TO direction before Q6
Q5b. When was the most recent time this happened? Was it ….
READ LIST
Less than 6 months ago………………………………….1 DM1=1
Six months ago but less than 12 months ago….…………2 DM1=1
12 months ago but less than 2 years……….…………….3 SKIP TO direction before Q6
2 years ago but less than 4 years…………….….……….4 SKIP TO direction before Q6
Four or more years ago……………………………….…..5 SKIP TO direction before Q6
(VOL) Don’t Know….……………………….……8 SKIP TO direction before Q6
(VOL) Refused……………………………….……9 SKIP TO direction before Q6
Q5c. How many times has this happened to you in the past 12 months?
_____________________ TIMES RANGE=1-7
DON'T KNOW=8 REFUSED=9
LOOP FOR EACH INCIDENT IN Q5c [MAX 4 LOOPS]
Q5d. In what month(s) did the (most recent/next most recent) crash occur?
1 December 2008
2 January 2009
3 February 2009
4 March 2009
5 April 2009
6 May 2009
7 June 2009
8 July 2009
9 August 2009
10 September 2009
11 October 2009
12 November 2009
13 December 2009
14 January 2010
15 February 2010
16 March 2010
17 April 2010
18 May 2010
98 (VOL) Don’t Know
99 (VOL) Refused
Q5e. In what state did the (most recent/next most recent) accident occur?
(ENTER TWO-LETTER STATE DESIGNATION)
Q5f. Were any other vehicles also damaged in (this/the next accident)?
Yes……….1
No…………2
Don’t Know.8
Refused……9
GO TO NEXT LOOP Q5d
IF (IN1=0 AND IN2=0 AND IN3=0 AND DM1=0), ASK Q6.
IF (IN1=0 AND IN2=0 AND IN3=0 AND DM1=1), SKIP TO Q23.
ELSE SKIP TO Q7a.
IF (IN1=1 OR IN2=1 OR IN3=1 OR DM1=1), QUAL 4.
IF (IN1=1 OR IN2=1 OR IN3=1 OR DM1=1), REPCRSH=1
Q6. Has anyone else in the household age 16 or older been in a motor vehicle crash in the past twelve months that involved either injury or property damage?
Yes ASK TO SPEAK TO THE PERSON (GO TO B)
No GO TO D1 – SET QUAL 5
(VOL) Don’t Know GO TO D1 – SET QUAL 5
(VOL) Refused GO TO D1 – SET QUAL 5
INJURY CRASH LOOPS (3 TOTAL)
INJURED AS DRIVER (IN1)
INJURED AS PASSENGER (IN2)
INJURED AS PEDESTRIAN (IN3)
Q7a. In the crash in (MONTH/most recent crash) in which you were injured (as a driver/as a passenger/as a pedestrian), did a police officer appear at the scene of the accident?
Yes………………1
No………………..2 SKIP TO Q8a
Don’t Know……...8 SKIP TO Q8a
Refused…………..9 SKIP TO Q8a
Q7b. To your knowledge, did the police fill out and file a report on the accident?
Yes………………1 SKIP TO Q8b(1)
No………………..2
Refused…………..9 SKIP TO Q8a
Q7c. Did the police inform you why they were not filing a report?
Yes………………1
No………………..2 SKIP TO Q8a
Don’t Know……...8 SKIP TO Q8a
Refused…………..9 SKIP TO Q8a
Q7d. Why did the police say they were not filing a report? Anything else?
[DO NOT READ. MULTIPLE RESPONSE]
Emergency Situation
Injuries not serious/severe enough
Damage to vehicle not serious/severe enough
Other party left before police arrived
Other (Please specify)______________
8. Don’t know
9. Refused
Q8a. Sometimes people don’t report car accidents because it is not necessary given their circumstances, or other times people are simply too busy or forget. Did you or someone in your household report this accident to the police?
Yes………………1 SKIP TO Q8b(1)
No………………..2
Don’t Know……...8
Refused…………..9
Q8b. To your knowledge, did anyone report the accident to the police?
Yes………………1 SKIP TO Q8b(1)
No………………..2
Don’t Know……...8 SKIP TO Q9
Refused…………..9 SKIP TO Q9
Q8b.(1) How did the accident get reported to the police?
In person when police arrived without having used a phone…..1
Called on home landline phone………………………………..2
Called on a cell phone…………………………………………3
Called on a pay phone…………………………………………4
Other (please specify) _________……………………………..7
Don’t Know…………………………………………………....8
Refused…………………………………………………….…..9
SKIP TO Q9
Q8c. Why didn’t you report the accident to the police? Anything else?
[DO NOT READ. MULTIPLE RESPONSE]
No Insurance
No License
Suspended License
Owes money for tickets
Will increase the cost of car insurance
Would be points on driving record
Less than deductible amount
Feared would be arrested
Driving employer-owned vehicle
Emergency Situation
Injuries not serious/severe enough
Damage to vehicle not serious/severe enough
Respondent left before police arrived
Other party left before police arrived
Other (Please specify)______________
98. Don’t know
99. Refused
(IF IN1=0 AND IN2=0 AND IN3=1), SKIP TO Q12A
Q9. In the crash in (MONTH/most recent crash) in which you were injured (as a driver/as a passenger), where was the vehicle you were in just before the crash happened? (IF SOMEWHERE ELSE, ASK WHERE)
On road/street/highway ………….1
Driveway ………………………..2
Parking Lot……………………..3
Somewhere else (Specify)……….4.
(VOL) Don’t Know…………….8.
(VOL) Refused…………………9…
Q10. What type of motor vehicle were you in at the time of the accident?
Automobile……………...1
SUV………………….…2
Van……………………..3
Pick-up Truck…………..4
Medium or Heavy Truck..5
Motorcycle/Moped……..6
Other (Specify).............…7
(VOL) Don’t Know…….8
(VOL) Refused…………9
Q11a. How many other motor vehicles (not including the vehicle you were in) were involved in the accident?
(Please include any parked cars or other vehicles.)
RECORD NUMBER_____ (Range 0-20, 20=20 or more)
None, single vehicle crash………..00
(Vol) Don’t Know………………..98
(Vol) Refused…………………….99
Q11b. Did the vehicle you were in collide with any objects other than another motor vehicle?
Yes……………………1
No……………………..2 SKIP TO Q11d
(VOL) Don’t Know……8 SKIP TO Q11d
(VOL) Refused………...9 SKIP TO Q11d
Q11c. With what other object(s) did the vehicle you were in collide? (SELECT ALL THAT APPLY) Anything else? [DO NOT READ. MULTIPLE RESPONSE]
Tree…………………………..1
Pole…………………………..2
Guardrail……………………...3
Embankment………………….4
Animal…………………….….5
Pedestrian/Person…………….6
Train………………………....7
Nonmotorized Vehicle………..8
Other(Specify)……………….97
(VOL) Don’t Know…………98
(VOL) Refused………………99
Q11d. Where was the most damage to the vehicle you were in?
Front……………………….1
Side………………………...2
Rear………………………..3
Top…………………………4
No damage to vehicle……..5
Other(Specify)……………….97
(VOL) Don’t Know…………98
(VOL) Refused………………99
Q12a What was the most serious injury you sustained as a direct result of the accident?
Scrape…………………………………………….1 SKIP TO Q 12g
Amputation………………………………………..2 SKIP TO Q 12g
Concussion………………………………………..3 SKIP TO Q 12g
Bruise……………………………………………..4 SKIP TO Q 12g
Dislocation (ankle, knee, elbow or shoulder)……….5 SKIP TO Q 12g
Fracture/Broken bone ……………………………..6 Sprain……………………………………………...7 SKIP TO Q 12g
Strain……………………………………………....8 SKIP TO Q 12g
Whiplash…………………………………………..9 SKIP TO Q 12g
Cuts that required stitches or glue…………………..10 SKIP TO Q 12g
Minor Burns……………………………………….11 SKIP TO Q 12g
Severe Burns……………………………………...12 SKIP TO Q 12g
Other (Specify)……………………………………97 SKIP TO Q 12g
(VOL) Don’t Know……………………………... 98 SKIP TO Q 12g
(VOL) Refused……………………………………99 SKIP TO Q 12g
None/No Injury…………………………………..15 Skip to 12a_1
Q12a_1 "You previously indicated that you were injured in a motor vehicle accident. When we asked what the most serious injury was, you indicated that you were not injured. Were you injured during the accident?
1.) Yes (return to Q12a for type of injury)
2.) No, I was not injured, but I had motor vehicle damage (skip to Q23)
3.) No, I was not injured and I did not have motor vehicle damage (skip to D1 and create a new term that goes to DISP=1113
8.) Don’t Know
9.) Refused
Q12b. What was broken? Anything else? [DO NOT READ. MULTIPLE RESPONSE.]
Hand/fingers……………..1
Arm……………………..2
Shoulder…………….…..3
Foot/toes………………..4
Leg……………………...5
Back…………………….6
Hip………………………7
Spine…………………….8
Skull……………………..9
Ribs……………………..10
Face/Nose…………..…..11
Other (Specify)………..97
(VOL) Don’t Know…..98
(VOL) Refused……….99
Q12c. Did the broken bone require surgery?
Yes……………………1
No…………………….2
(VOL) Don’t Know…...8
(VOL) Refused………..9
IF Q12b=8, ASK Q12d AND Q12e, ELSE SKIP TO Q12f
Q12d. Did the spine injury include weakness in a limb?
Yes……………………1
No…………………….2
(VOL) Don’t Know…...8
(VOL) Refused………..9
Q12e. Did the spine injury include paraplegia(paralysis of the lower half of the body with involvement of both legs)?
Yes……………………1
No……………………..2
(VOL) Don’t Know…....8
(VOL) Refused………...9
IF Q12b=10, ASK Q12f, ELSE SKIP TO Q12g
Q12f. How many ribs were fractured?
_____ (Number)
(VOL) Don’t Know………….98
(VOL) Refused………............99
Q12g. Did you lose consciousness?
Yes…………………….1
No……………………..2 SKIP TO Q12i
(VOL) Don’t Know……8 SKIP TO Q12i
(VOL) Refused………...9 SKIP TO Q12i
Q12h. How long were you told you had lost consciousness?
(Number of Days)……...1 _______
(Number of Hours)…….2 _______
(Number of Minutes)….3 _______
97= 97 or more
Don’t Know…….98
Refused…………99
Q12i. Did you require any kind of brain surgery?
Yes…………………….1
No……………………..2
(VOL) Don’t Know…....8
(VOL) Refused………...9
Q12j. Did you have any internal organ injuries (spleen, liver, kidney, etc.)?
Yes……………………1
No…………………….2 SKIP TO Q12m
(VOL) Don’t Know……8 SKIP TO Q12m
(VOL) Refused………..9 SKIP TO Q12m
Q12k. Did the internal organ injury/ies require surgery?
Yes…………………… 1
No……………………..2 SKIP TO Q12m
(VOL) Don’t Know……8 SKIP TO Q12m
(VOL) Refused………...9 SKIP TO Q12m
Q12 l. Was a chest tube required?
Yes…………………….1
No……………………..2
(VOL) Don’t Know……8
(VOL) Refused………...9
Q12m. Did you have a blood transfusion?
Yes……………………1
No…………………….2
(VOL) Don’t Know…..8
(VOL) Refused……….9
ASK Q13a ONLY IF “No/DK/Refused” to Q12c, Q12i, Q12k, AND Q12m, ELSE SKIP TO Q13b
Q13a Did you receive medical treatment for your injuries?
Yes……………………1
No……………………..2 SKIP TO Q14
(VOL) Don’t Know…....8 SKIP TO Q14
(VOL) Refused…………9 SKIP TO Q14
Q13b. Were you treated at ...?
READ LIST; RECORD ALL THAT APPLY
Yes No Not Refused
Know
(a) A hospital emergency room......... 1 2 8 9
(b) A doctor's office.............................. 1 2 8 9
(c) A clinic…………………......... 1 2 8 9
Urgent Care, First Care, or
minor emergency center 1 2 8 9
(e) The accident scene........................... 1 2 8 9
(f) SOMEWHERE ELSE (SPECIFY)... 1 2 8 9
Q14. Were you transported from the accident scene by ambulance or helicopter?
Yes, ambulance (or rescue vehicle).....1
Yes, helicopter...................................2
No, neither.........................................3
(VOL) Don't know..........................8
(VOL) Refused................................9
Q15a. Were you hospitalized overnight or longer as a result of your injuries from the crash?
Yes................................1
No.................................2 SKIP TO Q16a
(VOL) Don't know......8 SKIP TO Q16a
(VOL) Refused............9 SKIP TO Q16a
Q15b How long were you hospitalized?
Gave answers in days……..1
Gave answers in hours…….2
(VOL) Don’t. know………8
(VOL) Refused…………...9
Q15c______ DAYS (0-365)
Q15d ______ HOURS (1-23)
Q15e. Were you in an Intensive Care Unit (ICU) due to your injuries?
Yes……………………1
No…………………….2 SKIP TO Q16a
(VOL) Don’t Know……8 SKIP TO Q16a
(VOL) Refused………..9 SKIP TO Q16a
Q15f. Were you in Intensive Care more than 24 hours?
Yes……………………1
No……………………..2
(VOL) Don’t Know…....8
(VOL) Refused………...9
Q16a. Did you receive any continuing or follow-up treatment for your injuries?
Yes................................1
No.................................2 SKIP TO Q16c
(VOL) Don't know......8 SKIP TO Q16c
(VOL) Refused...........9 SKIP TO Q16c
Q16b Where did you receive this follow-up treatment?
(READ LIST AND MULTIPLE RECORD)
Was it at...........?
Yes No DK Refused
A doctor’s office..................................... 1 2 8 9
A physical therapist’s office.................... 1 2 8 9
A clinic................................................... 1 2 8 9
A hospital............................................... 1 2 8 9
A Chiropractor………………………….. 1 2 8 9
SOMEWHERE ELSE.................................. 1 2 8 9
(Specify)
Q16c. What is your best estimate in dollars for your medical costs? Include any costs that were covered by an insurance company.
$ _____ (Dollars) SKIP TO Q16e
999999998 Don’t Know
999999999 Refused
Q16d. Can you tell me if it was . . . .
$500 or less…………………….…1
$501 to $1,000……………………2
$1,001 to $2,500………………….3
$2,501 to $5,000…………………4
$5,001 to $10,000………………..5
More than $10,000……………….6
(VOL) Don’t Know......................8
(VOL) Refused.............................9
Q16e. Did you use medical insurance coverage to help pay for the care you received?
Yes.................................1
No..................................2
Don’t have insurance...….3
(VOL) Don't know........8
(VOL) Refused.............9
Q17a. Did your injuries from that accident prevent you from performing any of your normal activities during the last 12 months (for example, work or school)?
Yes......................................1
No.......................................2 [SKIP TO Q18]
(VOL) Don't know............8 [SKIP TO Q18]
(VOL) Refused..................9 [SKIP TO Q18]
Q17b If so, how many days?____ DAYS (0-365)
NUMBER: ___________Days
(VOL) Don’t know……..998
(VOL) Refused…..……..999
(IF IN1=0 AND IN2=0 AND IN3=1) SKIP to INSTRUCTION BEFORE Q21
Q18. In the crash in (MONTH/most recent crash) (when you were a driver/when you were a passenger) did the vehicle you were in need to be towed away?
Yes..............................................1
No...............................................2
(VOL) Don’t Know...................8
(VOL) Refused..........................9
Q19. Was the damage reported to an Auto insurance company?
Yes..............................................1
No...............................................2 SKIP TO Q20c
(VOL) Don’t Know...................8 SKIP TO Q20c
(VOL) Refused..........................9 SKIP TO Q20c
Q20a. Did the insurance company consider the vehicle you were in “totaled”?
Yes..............................................1
No...............................................2 SKIP TO Q20c
(VOL) Don’t Know...................8 SKIP TO Q20c
(VOL) Refused..........................9 SKIP TO Q20c
Q20b. If yes, please give the insurance company assessed or “totaled” car value amount.
$___Dollars SKIP TO Q21
999999998 Don’t Know SKIP TO Q21
999999999 Refused SKIP TO Q21
Q20c. What is your best estimate in dollars for repair costs to the vehicle you were in? Include any costs which were covered by the insurance company.
$ _____ (Dollars) SKIP TO Q21
999999998 Don’t Know
999999999 Refused
Q20d. Can you tell me if it was . . . .
$500 or less………………………1
$501 to $1,000……………………2
$1,001 to $2,500………………….3
$2,501 to $5,000………………..…4
$5,001 to $10,000…………………5
More than $10,000………………..6
(VOL) Don’t Know.......................8
(VOL) Refused..............................9
IF YES IN (Q2f OR Q3f OR Q4f), ASK Q21, ELSE SKIP TO INSTRUCTION BEFORE Q23
Q21. Excluding yourself, what was the most serious injury sustained as a direct result of the accident?
Scrape….…………………………………………….1 SKIP TO Q22
Amputation…………………………………………..2 SKIP TO Q22
Concussion…………………………………………..3 SKIP TO Q22
Bruise….…………………………………………….4 SKIP TO Q22
Dislocation (ankle, knee, elbow or shoulder)……….…5 SKIP TO Q22
Fracture/Broken bone ………………………………..6 continue 21a
Sprain………………………………………………..7 SKIP TO Q22
Strain………………………………………………...8 SKIP TO Q22
Whiplash…………………………………………….9 SKIP TO Q22
Cuts that required stitches or glue…………..……….10 SKIP TO Q22
Minor Burns……………………………………..…11 SKIP TO Q22
Severe Burns……………………………...………..12 SKIP TO Q22
Death……………………………………………….13 SKIP TO Q22
Other (Specify)………………………………….…97 SKIP TO Q22
(VOL) Don’t Know……………………..…………98 SKIP TO Q22
(VOL) Refused………………………………….…99 SKIP TO Q22
IF FRACTURE IN Q21, ASK Q21a, ELSE SKIP TO Q22
Q21a. What was broken? Anything else? [DO NOT READ. MULTIPLE RESPONSE]
Hand/fingers……………..1
Arm……………………..2
Shoulder…………….…..3
Foot/toes………………..4
Leg……………………...5
Back…………………….6
Hip………………………7
Spine…………………….8
Skull……………………..9
Ribs……………………..10
Face/Nose…………..…..11
Other (Specify)………..97
(VOL) Don’t Know…..98
(VOL) Refused……….99
Q22. Was this person transported from the accident scene by ambulance or helicopter?
Yes, ambulance (or rescue vehicle).....1
Yes, helicopter...................................2
No, neither.........................................3
(VOL) Don't know......................…8
(VOL) Refused...............................9
PROPERTY DAMAGE LOOPS (1 TOTAL)
(ASK IF IN1=0 AND IN2=0 AND IN3=0 AND DM1=1), ELSE SKIP TO D1
VEHICLE YOU WERE IN WAS DAMAGED (DM1)
Q23. In the crash in (MONTH/most recent crash) in which the vehicle you were in was damaged, did a police officer appear at the scene of the accident?
Yes..............................................1
No...............................................2 SKIP TO Q24
(VOL) Don’t Know....................8 SKIP TO Q24
(VOL) Refused...........................9 SKIP TO Q24
Q23a. To your knowledge, did the police fill out and file a report on the accident?
Yes..............................................1 SKIP TO Q24(a1)
No...............................................2
(VOL) Don’t Know....................8 SKIP TO Q25
(VOL) Refused...........................9 SKIP TO Q25
Q23b. Did the police inform you why they were not filing a report?
Yes..............................................1
No...............................................2 SKIP TO Q24
(VOL) Don’t Know....................8 SKIP TO Q24
(VOL) Refused...........................9 SKIP TO Q24
Q23c. Why did the police say they were not filing a report? Anything else?
[DO NOT READ. MULTIPLE RESPONSE]
Emergency Situation
Injuries not serious/severe enough
Damage to vehicle not serious/severe enough
Other party left before police arrived
Other (Please specify)______________
8. Don’t know
9. Refused
Q24. Sometimes people don’t report car accidents because it is not necessary given their circumstances, or other times people are simply too busy or forget. Did you or someone in your household report the accident to the police?
Yes..............................................1 SKIP TO 24(a1)
No...............................................2
(VOL) Don’t Know....................8
(VOL) Refused...........................9
Q24a To your knowledge, did anyone report the accident to the police?
Yes..............................................1
No...............................................2 SKIP TO 24(b)
(VOL) Don’t Know....................8 SKIP TO 25
(VOL) Refused...........................9 SKIP TO 25
Q24(a1) How did the accident get reported to the police?
In person when police arrived without having used a phone…..1
Called on home landline phone………………………………..2
Called on a cell phone…………………………………………3
Called on a pay phone…………………………………………4
Other (please specify) _________……………………………..7
(VOL) Don’t Know...............………………………………....8
(VOL) Refused........................………………………………..9
SKIP TO Q25
Q24b Why didn’t you report the accident to the police? Anything else?
[DO NOT READ. MULTIPLE RESPONSE]
No Insurance
No License
Suspended License
Owes money for tickets
Will increase the cost of car insurance
Would be points on driving record
Less than deductible amount
Feared would be arrested
Driving employer-owned vehicle
Emergency Situation
Injuries not serious/severe enough
Damage to vehicle not serious/severe enough
Respondent left before police arrived
Other party left before police arrived
Other (Please specify)______________
98. Don’t know
99. Refused
Q25. In the crash in (MONTH/most recent crash) in which the vehicle you were in was damaged, where was the vehicle just before the crash happened?
On road/street/highway………….1
Driveway………………………..2
Parking Lot……………………...3
Somewhere else (Specify)……….4
(VOL) Don’t Know……………..8
(VOL) Refused……………….…9
Q26. What type of motor vehicle were you in at the time of the accident?
Automobile…………………..1
SUV…………………………2
Van…………………………..3
Pick-up Truck………………..4
Medium or Heavy Truck.….…5
Motorcycle/Moped………….6
Other (Specify)........................7
(VOL) Don’t Know………….8
(VOL) Refused………............9
Q27. How many other motor vehicles (not including the vehicle you were in) were involved in the accident?
RECORD NUMBER_____(Range 0-20, 20=20 or more)
None, single vehicle crash………..00
(VOL) Don’t Know………………98
(VOL) Refused……….........……..99
Q28. Did the vehicle you were in collide with any objects other than another motor vehicle?
Yes..............................................1
No................................................2 [SKIP TO Q30]
(VOL) Don’t Know....................8 [SKIP TO Q30]
(VOL) Refused...........................9 [SKIP TO Q30]
Q29. With what other object(s) did the vehicle you were in collide? (SELECT ALL THAT APPLY) Anything else? [DO NOT READ. MULTIPLE RESPONSE]
Tree…………………………..1
Pole…………………………..2
Guardrail……………………..3
Embankment…………………4
Animal………………………..5
Pedestrian/Person………….....6
Train…………………………7
Nonmotorized Vehicle………..8
Other(Specify)……………….97
(VOL) Don’t Know…………10
(VOL) Refused……………...11
Q30. Where was the most damage to the vehicle you were in?
Front……………………….1
Side………………………...2
Rear………………………..3
Top…………………………4
No damage to vehicle……..5
Other(Specify)……………….97
(VOL) Don’t Know…………98
(VOL) Refused………………99
Q31. In the crash in (MONTH/most recent crash) in which the vehicle you were in was damaged, did the vehicle need to be towed away?
Yes..............................................1
No...............................................2
(VOL) Don’t Know...................8
(VOL) Refused..........................9
Q32. Was the damage reported to an Auto insurance company?
Yes..............................................1
No...............................................2 SKIP TO Q33c
(VOL) Don’t Know...................8 SKIP TO Q33c
(VOL) Refused..........................9 SKIP TO Q33c
Q33a. Did the insurance company consider the vehicle you were in “totaled”?
Yes..............................................1
No...............................................2 SKIP TO Q33c
(VOL) Don’t Know...................8 SKIP TO Q33c
(VOL) Refused..........................9 SKIP TO Q33c
Q33b. If yes, please give the insurance company assessed or “totaled” car value amount.
$___Dollars SKIP TO D1
999999998 Don’t Know SKIP TO D1
999999999 Refused SKIP TO D1
Q33c. What is your best estimate in dollars for repair costs to the vehicle you were in? Include any costs which were covered by the insurance company.
$ _____ (Dollars) SKIP TO D1
999999998 Don’t Know
999999999 Refused
Q33d. Can you tell me if it was . . . .
$500 or less………………………1
$501 to $1,000……………………2
$1,001 to $2,500…………………3
$2,501 to $5,000…………………4
$5,001 to $10,000………………..5
More than $10,000……………….6
(VOL) Don’t Know......................8
(VOL) Refused.............................9
IF (IN1=1 OR IN2=1 OR IN3=1 OR DM1=1), QUAL 6.
DEMOGRAPHICS
D1. Now I need to ask you some basic information about you and your household. What is your age?
__________ AGE RANGE=16-97 SKIP TO P1
DON’T KNOW=98
REFUSED=99
D2. Please tell me which age range your current age falls under.
16 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
DON’T KNOW
REFUSED
P1. PROGRAMMING VARIABLE
IF ((Q8b=2, 8, OR 9) OR (Q24a=2, 8, OR 9)) REPCRSH=2.
P2. PROGRAMMING VARIABLE
INITIALIZE AGECAT7=D2.
IF (D1≥16 AND D1≤24) AGECAT7=1.
IF (D1≥25 AND D1≤34) AGECAT7=2.
IF (D1≥35 AND D1≤44) AGECAT7=3.
IF (D1≥45 AND D1≤54) AGECAT7=4.
IF (D1≥55 AND D1≤64) AGECAT7=5.
IF (D1≥65 AND D1≤74) AGECAT7=6.
IF (D1≥75 AND D1≤97) AGECAT7=7.
IF (D1=98 OR D1=99) AGECAT7=8.
D3. Do you consider yourself to be Hispanic or Latino?
Yes....................................1
No.....................................2
(VOL) Don’t Know.........8
(VOL) Refused................9
D4. Which of the following racial categories describes you? You may select more than one.
READ LIST AND MULTIPLE RECORD.
American Indian or Alaska Native..................1
Asian...........................................................…2
Black or African‑American...............................3
Native Hawaiian or Other Pacific Islander.........4
White...............................................................5
(VOL) Hispanic/Latino ………………..…..6
(VOL) Other (SPECIFY)………………….7
(VOL) Don’t Know………………………..8
(VOL) Refused..................................………9
D5. What is the highest grade or year of school you completed?
8th grade or less.............................1
9th grade........................................2
10th grade.....................................3
11th grade.....................................4
12th grade/GED............................5
Some college.................................6
College graduate or higher.........….7
(VOL) Don’t know…………….8
(VOL) Refused...........................9
D6. Which of the following categories best describes your total household income before taxes in 2008? (Includes the income of all persons in the household.) Was your total household income [READ LIST]
Less than $5,000............................1
$5,000 to $14,999..........................2
$15,000 to $29,999........................3
$30,000 to $49,999........................4
$50,000 to $74,999........................5
$75,000 to $99,999........................6
$100,000 or more...........................7
Don’t Know (VOL)..................….8
Refused…………………………..9
D7. How many different landline telephone numbers do you have at your residence at which you
can normally receive incoming phone calls?
___________ 10 OR MORE=10 DON'T KNOW=98 REFUSED=99
D8. Do you or anyone in your family have a working cell phone?
1 Yes
2 No (SKIP TO D11)
8 Don’t know
9 Refused
D9 How many working cell phones do you or people in your family have?
(1-10 cell phones) ____
D10 Of all the telephone calls that you or your family receives, are...
[READ LIST.]
1 All or almost all calls received on cell phones
2 Some received on cell phones and some on regular phones
3 Very few or none on cell phones
Don’t know
Refused
D11 Do you… READ LIST.
1 Rent your home or apartment
2 Own your own home
3 Live with family or friends and pay part of the rent or mortgage
4 Live with family or friends and do not pay rent
7 Other, Specify
8 DON’T KNOW
9 REFUSED
D12. Interview was conducted in:
English...........1
Spanish........…2
That completes the survey.
Thank you very much for your time and cooperation.
| File Type | application/msword |
| Author | Valued Gateway Client |
| Last Modified By | walter.culbreath |
| File Modified | 2010-05-25 |
| File Created | 2010-05-25 |