CONTROL
MOTORCYCLE RIDER QUESTIONNAIRE
1. Case Number ____________ 2. Motorcycle Rider Number ____
BACKGROUND INFORMATION
3. How old are you? ___ ___
Code actual age in years
(99) unknown
4. Where did you get your current driver's license? _____
(1) no license
(2) California
(3) other State (list) ________
(4) Canada
(5) Mexico
(6) military
(8) other (describe) ____________
(9) unknown
5. What kind of operator's license is it? ___ ___
(Code up to 4; input "97" in remaining responses) ___ ___
(01) no license held ___ ___
(02) learner's permit, only ___ ___
(03) motorcycle license
(04) automobile license
(05) commercial license
(06) motorcycle driver and competition license
(07) license to transport people
(08) heavy truck license
(97) not applicable
(98) other (describe) ___________
(99) unknown
6. What year was/were the license(s) issued? __ __ __ __A.5.1.1.6.1
(Listed in same order as licenses above) __ __ __ __A.5.1.1.6.2
(9997) not applicable __ __ __ __A.5.1.1.6.3
(9999) unknown __ __ __ __A.5.1.1.6.4
7. Are you of Hispanic or Latino origin? ____
(0) refused to answer
(1) no
(2) yes
(8) other (describe) __________
(9) unknown
8. What is your race? ___
Please select one or more, code “7” in others ___
(0) refused to answer ___
(1) white ___
(2) black or African American
(3) Asian
(4) Native Hawaiian or other Pacific Islander
(5) American Indian or Alaska native
(7) not applicable
(8) other _________________________
(9) unknown
9. What is your height? ___ft. ___ ___ in. A.5.1.1.9
(9/99) unknown
10. What is your weight? ___ ___ ___lbs. A.5.1.1.10
(999) unknown
11. Gender ___ A.5.1.1.11
(1) male
(2) female
(9) unknown
12. How much formal education have you had? ___ ___ A.5.1.1.12
(01) no formal schooling
(02) less than high school diploma
(03) high school diploma or GED
(04) partial college/university
(05) college/university graduate
(06) graduate school, advanced degree, professional degree
(07) specialty/technical school
(97) not applicable
(98) other (specify) ___________
(99) unknown
15. What is your current occupation? ___ ___ A.5.1.1.13
(11) management occupations
(13) business and financial
(15) computer and mathematical
(17) architecture and engineering
(19) life, physical, and social science
(21) community and social services
(23) legal
(25) education, training or library
(27) arts, design, entertainment, sports or media
(29) healthcare practitioners and technical jobs
(31) healthcare support
(33) protective services
(35) food preparation and serving related
(37) building and grounds maintenance
(39) personal care and services
(41) sales and related occupations
(43) office and administrative support
(45) farming, fishing or forestry
(47) construction or extraction
(49) installation, maintenance or repair
(53) transportation and material moving
(55) military
(60) full time student
(97) not applicable, not in workforce at present
(98) other (specify) _____________
(99) unknown
RIDING/DRIVING EXPERIENCE
14. Are you the owner of this motorcycle? ___
(1) no
(2) yes
(8) other __________________
(9) unknown
15. How many YEARS have you been driving any kind of motor vehicle? ___ ___ years
(00) less than two weeks
(01) one year or less
(02-96) actual number of years
(97) not applicable/no previous experience/first time
(99) unknown
16. How many MONTHS have you operated a street motorcycle? ___ ___ ___
(000) this is the first time
(001) less than or equal to one month
(002-095) actual number of months
(096) 96 months or more
(997) not applicable
(998) other (specify) __________
(999) unknown
17. What is the average number of days per year you ride motorcycles? ___ ___ ___
(001-365) Actual number of days per year
(997) not applicable, first time
(999) unknown
18. About how many miles per year do you ride motorcycles? ___ ___ ___ ___ ___
(00000) none
(00001-99995) actual miles
(99996) 99996 or greater miles
(99998) other (specify) ____
(99999) unknown
19. What kind of motorcycle training have you had? ___ ___
(00) none
(01) self taught
(02) taught by family or friends
(03) special voluntary motorcycle training for road riding
(04) special compulsory motorcycle training for road riding
(05) professional training for competition license
(06) advanced training
(07) compulsory motorcycle training ordered by judge/police/etc.
(98) other (specify) __________________
(99) unknown
20. When you ride a motorcycle, what is the percentage of time you use it for each of these categories? (indicate % of total riding/driving time for each of the three categories)
Recreation ___ ___ ___ %
Basic transportation ___ ___ ___ %
100%
(000) first time use
(997) not applicable
(999) unknown
21. How much experience do you have riding with passengers on a motorcycle? ___
(1) first time carrying passenger(s)
(2) very little experience
(3) moderate experience
(4) extensive experience
(7) not applicable, never carry passengers
(9) unknown
22. How much experience do you have riding with cargo/luggage? ___
(1) first time
(2) seldom carries similar cargo/luggage
(3) frequently carries similar cargo/luggage
(4) always carries similar cargo/luggage
(7) not applicable/no experience with cargo/luggage
(9) unknown
23. How many moving traffic convictions have you had in the previous 5 years?
Code the total number of moving traffic convictions – any vehicle ___ ___
(00) none
(99) unknown
24. Of those how many were motorcycle moving traffic crashes? ___ ___
Code the total number of previous motorcycle moving violations
(00) none
(99) unknown
25. Of those how many were car or truck moving traffic crashes? ___ ___
Code the total number of previous car or truck moving violations
(00) none
(99) unknown
TRIP INFORMATION
26. At what kind of location did you begin your trip today? ___ ___
(01) home
(02) work, business
(03) recreation/social
(04) school/religious activity
(05) errand, shopping
(06) family personal business/obligations
(07) meals, restaurant, etc.
(08) transport someone
(09) medical/dental
(10) bar, pub
(98) other (specify) _____________
(99) unknown
27. What was your trip destination? ___ ___ A.5.1.1.28
(01) home
(02) work, business
(03) recreation/social
(04) school/religious activity
(05) errand, shopping
(06) family personal business/obligations
(07) meals, restaurant, etc
(08) transport someone
(09) medical/dental
(10) bar, pub
(11) no destination, joy riding
(98) other (specify) _____________
(99) unknown
28. About how many miles would the trip have been one way? ___ ___ ___ A.5.1.1.29
(001) one mile or less
(002-995) actual number of miles
(996) 996 miles or greater
(997) not applicable
(999) unknown
29. How many hours have you been riding today since your trip departure ?___ ___
(01) one hour or less
(02-95) actual hours
(96) 96 or more
(97) not applicable, had not yet begun trip
(98) other (specify) ___________
(99) unknown
30. How many miles have you gone since your trip departure? ___ ___ ___
(001) one mile or less
(002-095) actual hours
(096) 96 or more
(997) not applicable, had not yet begun trip
(998) other (specify) ___________
(999) unknown
PROTECTIVE CLOTHING/GEAR WHEN RIDING
31. What kind of clothing was on your upper body? ___
(0) none
(1) light cloth garment, i.e., thin cotton
(2) medium cloth garment, i.e., denim, nylon
(3) heavy cloth garment, i.e., imitation leather
(4) leather garment
(5) Kevlar
(8) other (specify)
(9) unknown
32. Was this upper body clothing motorcycle-oriented? ___ A.5.3.1.2
(1) no
(2) yes
(7) not applicable/no clothing
(8) other (specify) ________
(9) unknown
33. What kind of clothing was on your lower body? ___ A.5.3.1.3
(0) none
(1) light cloth garment, i.e., thin cotton
(2) medium cloth garment, i.e., denim, nylon
(3) heavy cloth garment, i.e., imitation leather
(4) leather garment
(5) Kevlar
(8) other (specify)
(9) unknown
34. Was this lower body clothing motorcycle-oriented? ___ A.5.3.1.4
(1) no
(2) yes
(7) not applicable/no clothing
(8) other (specify) ________
(9) unknown
35. Were you wearing an inflatable safety vest? ____
(1) no
(2) yes
(8) other (specify) ___
(9) unknown
36. What kind of shoes or boots were you wearing? ___ A.5.3.1.5
(1) no shoes or boots, barefoot
(2) light sandal
(3) medium street shoe, loafer
(4) athletic, training shoe
(5) heavy shoe or boot
(6) reinforced work boot or motorcycle boot
(8) other (specify) _______
(9) unknown
37. Did this footwear go up over your ankle? ___
(1) no
(2) yes
(7) not applicable, no footwear worn
(8) other, specify __________________
(9) unknown
38. Was the footwear motorcycle-oriented? ___ A.5.3.1.6
(1) no
(2) yes
(7) not applicable, no footwear worn
(9) unknown
39. What kind of gloves were you wearing? ___ A.5.3.1.7
(0) none
(1) light cloth garment, i.e., thin cotton
(2) medium cloth garment, i.e., denim, nylon
(3) heavy cloth garment, i.e., imitation leather
(4) leather garment
(5) Kevlar
(8) other (specify)
(9) unknown
40. Are the gloves motorcycle-oriented? ___ A.5.3.1.8
(1) no
(2) yes, full fingered
(3) yes-shorties
(7) not applicable, no gloves worn
(8) other (specify) ______
(9) unknown
41. Is any of this clothing retroreflective? _____
Code up to 3 responses _____
(1) no retroreflective clothing or gloves _____
(2) upper body (shirt/jacket/vest)
(3) lower body (pants/ shorts)
(4) gloves
(5) special arm bands, or similar items
(7) not applicable, no clothing or gloves
(8) other (specify) _________
(9) unknown
42. What is the clothing color of the following?
Upper body clothing ___ ___ D.5.3.1.6.1
Lower body clothing ___ ___ D.5.3.1.6.2
Footwear ___ ___ D.5.3.1.6.3
Gloves ___ ___ D.5.3.1.6.4
(01) no dominating color, multi-colored
(02) white
(03) yellow
(04) black
(05) red
(06) blue
(07) green
(08) silver
(09) orange
(10) brown
(11) purple
(12) gold
(13) grey
(97) not applicable/no clothing
(98) other (specify) ________
(99) unknown
43. Do you think any of your clothing helped with your ability to safely operate your motorcycle?
Upper body clothing ___ ___
Lower body clothing ___ ___
Footwear ___ ___
Gloves ___ ___
(01) apparel had no effect
(02) apparel protected or helped rider
(03) apparel uncomfortable or distracting
(97) not applicable, no apparel
(98) other, specify ________________
(99) unknown
44. What kind of eye protection do you usually wear? ___ ___
(01) none
(02) non-prescription clear glasses
(03) prescription clear glasses
(04) non-prescription sunglasses
(05) prescription sunglasses
(06) goggles, non-prescription
(07) goggles, prescription
(08) industrial safety glasses
(98) other (specify) ____________
(99) unknown
45. Are you required to wear corrective lenses when riding/driving? ___
(1) no
(2) yes
(8) other specify____________________
(9) unknown
46. What color was the eye coverage lens? ___
(1) clear
(2) green
(3) grey, smoke
(4) amber, yellow
(5) blue
(6) reflective (any color)
(7) not applicable, not wearing eye coverage
(8) other (specify) __________________________
(9) unknown
HELMET DATA
47. Do you usually wear a helmet? ___ A.5.3.1.11
(1) no
(2) yes
(3) helmet available, but not used
(8) other (specify) ______
(9) unknown
48. What is your reason for not wearing a helmet? ___ ___ D.5.2.1.1.13
(01) not required by law
(02) no expectation of accident involvement
(03) helmets too expensive
(04) helmets are inconvenient and uncomfortable
(05) helmets reduce traffic awareness, limit hearing and vision
(06) helmets ineffective in reducing head injury
(07) helmets cause neck injury
(08) helmets can not be used, physical or religious reasons
(09) do not own a helmet
(10) forgot to bring helmet today
(97) not applicable, rider always wears a helmet
(98) other (*describe, 80 characters) ________________________
(99) unknown
IF NO HELMET WAS WORN, go to IMPAIRMENT section.
49. Is your helmet properly adjusted? ___ A.5.3.1.12
(1) no
(2) yes
(7) not applicable, no helmet
(8) other (specify) ______
(9) unknown
50. Is your helmet securely fastened? ___ A.5.3.1.13
(1) no
(2) yes
(7) not applicable, no helmet
(8) other (specify) ______
(9) unknown
51. What type of helmet is it? ___ A.5.3.1.14
(1) not a motorcycle helmet
(2) half/police motor vehicle, motorcycle helmet
(3) open face motor vehicle, motorcycle helmet
(4) full face motor vehicle, motorcycle helmet
(5) novelty helmet
(7) not applicable, not helmet
(8) other (specify)
(9) unknown
52. What is the type of helmet coverage? ___ ___ A.5.3.1.15
(11) partial coverage
(12) full coverage
(13) full facial, integral chin bar but no face shield
(14) full facial, removable chin bar
(15) full facial, retractable chin bar
(16) full facial coverage, integral chin bar and face shield
(17) wrap around face shield
(18) bubble type face shield
(19) visor/face shield combo
(97) not applicable/no helmet
(98) other (specify)
(99) unknown
53. What is the predominant color of your helmet? ___ ___ A.5.3.1.16
(01) no dominating color, multi-colored
(02) white
(03) yellow
(04) black
(05) red
(06) blue
(07) green
(08) silver, grey
(09) orange
(10) brown, tan
(11) purple
(12) gold
(13) chrome, metallic
(97) not applicable/no helmet
(98) other (specify) ________
(99) unknown
54. What is the color of the face shield? ___ A.5.3.1.17
(1) clear
(2) green
(3) grey, smoke
(4) amber, yellow
(5) blue
(6) reflective (any color)
(7) not applicable/no face shield
(8) other (specify) ________
(9) unknown
55. Do you own this helmet? ___ A.5.3.1.18
(1) no
(2) yes
(7) not applicable, no helmet
(8) other (specify) ______
(9) unknown
56. How well does this helmet fit? ___ A.5.3.1.19
(1) acceptable fit
(2) too large, too loose
(3) too small, too tight
(7) not applicable/no helmet
(8) other (specify) ____________________
(9) unknown
57. What percentage of time do you wear your helmet when riding? ___ ___ ___ %
Code from 001-100 percent A.5.3.1.20
(997) not applicable/no helmet
(999) unknown
58. Under what conditions do you usually wear your helmet? ___ A.5.3.1.21.1
(code up to four; input "7" for remaining responses) ___ A.5.3.1.21.2
(1) never uses helmet ___ A.5.3.1.21.3
(2) long trips ___ A.5.3.1.21.4
(3) highway traffic
(4) in adverse weather
(5) never in hot weather
(6) always
(7) not applicable/no helmet
(8) other (specify) __________
(9) unknown
IMPAIRMENT
59. Do you have any of the following permanent physical conditions?___ ___ A.5.1.1.39.1
(Code up to three; input "01" in remaining responses) ___ ___ A.5.1.1.39.2
(01) no ___ ___ A.5.1.1.39.3
(02) vision reduction or loss
(03) hearing reduction or loss
(04) respiratory, cardiovascular condition
(05) paraplegia
(06) amputee
(07) neurological, epilepsy, stroke
(08) endocrine system, diabetes, digestive system
(09) infirmity, arthritis, senility
(98) other (specify) ____________
(99) unknown
60. Are you experiencing any of the following?
(Code up to three; input "01" in remaining responses) ___ ___ A.5.1.1.40.1
(01) no ___ ___ A.5.1.1.40.2
(02) fatigue ___ ___ A.5.1.1.40.3
(03) hunger
(04) thirst
(05) elimination urgency
(06) muscle spasm, cramp, itch
(07) headache, minor malaise, fever
(08) siesta syndrome (tired in afternoon)
(98) other (specify) _______________
(99) unknown
61. Are you concerned about any of the following issues today?
(Code up to three; input "01" in remaining responses) ___ ___ A.5.1.1.41.1
(01) no problems ___ ___ A.5.1.1.41.2
(02) conflict with friends, relatives, divorce, separation ___ ___ A.5.1.1.41.3
(03) work related problems
(04) financial distress
(05) school problems
(06) legal, police problems
(07) reward stress
(08) traffic conflict, road rage
(09) death of family, friend
(98) other (specify) ______________
(99) unknown
62. How many hours of sleep did you have in the past 24 hours? ____ ____
(00) no sleep
(01-24) number of hours slept
(98) other (specify) _______________
(99) unknown
63. Did you drink any alcohol or take any drugs or medications today? ___
(1) no A.5.1.1.32
(2) alcohol use, only
(3) drug/medication use, only
(4) combined alcohol and drug/medication use
(8) other, _________________________________
(9) unknown
64. Type of drugs other than alcohol? ___ A.5.1.1.37
(1) no drugs other than alcohol
(2) stimulant
(3) depressant
(4) drugs taken, type unknown
(5) multiple drugs taken
(7) not applicable, no drugs or alcohol
(8) other (specify)__________________
(9) unknown
65. Source of drugs other than alcohol? ___ A.5.1.1.38
(1) no drugs other than alcohol
(2) prescription
(3) non-prescription, over the counter
(4) illegal
(7) not applicable, no drugs or alcohol
(9) unknown
| File Type | application/msword |
| File Title | Case Number ____________ |
| Author | Louise Woodruff |
| File Modified | 2007-06-08 |
| File Created | 2007-06-08 |