Form NHTSA 1106 NHTSA 1106 ATT C2 NCRUSS Interview-Vehicle

A TTACHMENT C2

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 2127-0642. Public reporting for this collection of information is estimated to be approximately 4 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. NHTSA Form 1106

United States Department of Transportation National Highway Traffic Safety Administration

INTERVIEW FORM VEHICLE (3/10/11 Draft)

Form Approved O.M.B. No. 2127-0642 Expiration Date: xxxx National Automotive Sampling System National Child Restraint Use – Special Study

(Site Information)

1. Primary Sampling Unit Number: _____ _____

2. Site Number: _____ _____

3. Observation Number: _______/_______

4. Date of Observation: _______/_______/2011

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5. Do you have any passengers < 9 years of age?

   1. O Yes 2) O No or Don’t Know (End Interview)

6. Interview Start Time: _______________________

7. Interview Conducted in:

   1. O English 2) O Spanish

8. Year: ___________________________ O DK

9. Make: _____________________________

10. Model: _______________________________

11. What is the total # of occupants in this vehicle:

    1. _________________________________

    2. O DK, Ref, or DA (Circle one)

12. Have you ever seen or heard of a “booster seat”?

    1. O Yes

    2. O No (Skip to Q15)

    3. O DK, Ref, or DA (Circle one) (Skip to Q15)

13. What is the minimum age that a child should be to use a booster seat?

    1. O Age (Specify) __________________

    2. O DK, Ref, or DA (Circle one)

14. Why is a booster seat used? (Don’t read options; Check all that apply.)

    1. To make the safety belt fit the child better

    2. It is the law

    3. So the child can see out of the windows

    4. Safety

    5. DK, Ref, or DA (Circle one)

    6. Other: _______________________

15. When is it safe for your child to use a safety belt without either a booster seat or child safety seat? (Don’t read options; Check all that apply.)

    1. Weight ______________________

    2. Age: ________________________

    3. Height: ______________________

    4. Child’s knees reach the edge of vehicle seat

    5. Child is tall enough that shoulder belt doesn’t cut across the chin/neck.

    6. Child can keep his/her feet flat on the floor.

    7. DK, Ref, or DA (Circle one)

    8. Other: ____________________________

16. Do you know about a way to install a child safety seat without a safety belt?

    1. O Yes

    2. O No (Skip to Q18)

    3. O DK, Ref, or DA (Circle one) (Skip to Q18)

17. What is it called?

    1. O LATCH (Skip to Q19)

    2. O Tether

    3. O ISOFIX

    4. O DK, Ref, or DA (Circle one)

    5. O Other

18. Have you heard of the term “LATCH” associated with child safety seats?

    1. O Yes

    2. O No

    3. O DK, Ref, or DA (Circle one)

19. Does your vehicle have a place to connect or anchor the lower attachments for a child safety seat?

    1. O Yes

    2. O No (Skip to Q21)

    3. O DK, Ref, or DA (Circle one) (Skip to Q21)

20. Can you see the lower anchors, or are they hidden between the seat cushions?

    1. O Can see the lower anchors

    2. O Hidden

    3. O DK, Ref, or DA (Circle one)

21. Does your vehicle have a place to hook or anchor the top tether strap for a child safety seat?

    1. O Yes

    2. O No (Skip to Q23)

    3. O DK, Ref, or DA (Circle one) (Skip to Q23)

22. Can you see the tether anchors, or are they hidden?

    1. O Can see the tether anchors

    2. O Hidden

    3. O DK, Ref, or DA (Circle one)

23. In your opinion: How good are child safety seats at preventing injuries for children <2 years old, when compared to using only a seat belt? How about for 2-4 year olds? (Read options; Mark as appropriate)

    	Not as good	The Same	Better Than SBs	DK, Ref, or DA (Specify)
    < 2 Yrs
    2-4 Yrs

24. Using the same options as in the last question, in your opinion, for children ages 4 to 8, how good are booster seats at preventing injuries, when compared to using only a seat belt?

    	Not as good	The Same	Better Than SBs	DK, Ref, or DA (Specify)
    4-8 Yrs

25. Did you ever read or hear of any information or receive any advice about the need to use child safety seats from any of the following sources? (Read options; Check all that apply)

    1. A doctor, nurse, or hospital personnel?

    2. A book, magazine, or article?

    3. Store (e.g., Babies R Us)

    4. A daycare provider

    5. TV or radio

    6. A family member or friend

    7. A safety hotline

    8. The Internet

    9. Police or fire department

    10. Car class/car safety seat check station

    11. None

    12. DK, Ref, or DA (Circle one)

    13. Other (Specify) _____________________