NHTSA Form 1115 Screening Questions

OMB Control No. 2127-xxxx

Expiration Date xx, xx, xxxx

Screening Questions for DADDS Focus Group

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-XXXX. Public reporting for this collection of information is estimated to be approximately 90 minutes per focus group, 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

Recruitment goal: recruit 11 to seat 8

Ask to speak with someone who is at least 21. If none at home, terminate.

Hello. My name is _______ and I’m calling from ___________, a local research firm. We are conducting a study in this area about alcohol use and driving. Let me assure you that this is not a sales call; we are simply interested in your opinions. We are organizing several group discussions on this topic. If you are invited to attend one of the group discussions, you will be paid $75 for your opinions about alcohol use and driving. Would you be interested in participating in this study?

( ) Yes Continue

( ) No Terminate

Record gender Male ( ) Female ( )

Now I’d like to ask you several questions to determine your eligibility for the group discussions.

1. Do you have a valid driver’s license?

( ) Yes Continue

( ) No Terminate

2. During the past 60 days have you had an alcoholic drink? (Note: Terminate if the candidate’s response corresponds to a group that is full.)

( ) Yes Continue to Q 3.

( ) No Continue to Q 4 (nondrinker)

3. What is the maximum number of drinks you have had on at least one occasion during the past 60 days

( ) Drank 1 to 4 drinks in a single sitting (men),

Drank 1 to 3 drinks in a single sitting (women)

Continue to Q4 (social drinker)

( ) Drank 5 or more drinks in a single sitting (men)

Drank 4 or more drinks in a single sitting (women)

Continue to Q4 (heavy episodic drinker)

4. In the past year, have you participated in a market research study or interview where you were paid for your time and for providing your opinions?

( ) Yes Terminate

( ) No Continue

5. Do you, or does anyone in your household, work in or is retired from any of the following industries?

( ) Public relations Terminate

( ) Advertising Terminate

( ) Market research Terminate

( ) Marketing Terminate

( ) Liquor sales or hospitality (bar tending) Terminate

( ) No Continue

6. Finally, can you tell me about a television show, book or movie that you have seen lately that you enjoyed? What did you like about it?

This question is intended to establish whether the candidate is reasonably articulate and willing to converse. It is very important that participants can express themselves and are willing to talk.

Invitation

Thank you for answering my questions. I would like to tell you a little more about the study. This is strictly a research project; no one will try to sell you anything. The group interview will last approximately 1½ hours and you will be talking about in-vehicle technology for detecting a driver who is under the influence of alcohol. You will be reimbursed $75 to cover your expenses.

We will be holding a session on:

1) Date 1, 6 p.m., (nondrinkers)

2) Date 1, 8 p.m., (social drinkers)

3) Date 2, 7 p.m., (heavy episodic drinkers)

Will your schedule permit you to attend this session?

( ) Yes Continue

( ) No Terminate

So that we can start and end on time, please plan to arrive about 10 minutes early. We are counting on your participation, so if for any reason you cannot attend, please be sure to contact us as soon as possible. (Give phone number.)

Before we hang up, let me get the correct spelling of your name and your address and phone numbers so we can send you a confirmation letter with directions to our facility and give you a reminder call the day of the interview.

Name

Phone

Address

Thank you again for your time and we’ll see you on ___________.

Date recruited

Recruiter name

Date of confirmation letter

Confirmation call made

Attended:

Yes

No

NHTSA Form 1115 Page 3