NHTSA Form 1140 CM Omni Screener

OMB Control No. 2127-0667

Expiration Date 10/31/2013

RECRUITMENT SCREENER FOR FOCUS GROUPS

A COMBINED MESSAGE RELATED TO SPEEDING,

SEAT BELT USE AND IMPAIRED DRIVING

Generic Clearance OMB# 2127-0667

NOTE TO RECRUITER: Ask to speak to any male age 18 to 34 (note: sex and age range are critical). If none available, terminate.

Hello, I'm __________________ calling for the (NAME OF FOCUS GROUP COMPANY). We are conducting a brief survey among people in our area about driving.

(INTERVIEWER NOTE: If necessary,read): 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 2127-0667. Public reporting for this collection of information is estimated to be approximately 10 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

Could we begin now?

Do you, or does anyone in your immediate family, work in any of the following industries or professions? (NOTE TO RECRUITER: Read list. Terminate if “yes”

to any)

__ Marketing, advertising, public relations or marketing research

__ Graphic design

__ News media, including newspaper, television, radio or publishing

__ Alcohol, beer, wine and spirits

__ Law enforcement

__ Legal

__ Local, state or Federal Government

Are you a licensed driver?

____ Yes ____ No (terminate)

In which of these age groups is your age? (NOTE TO RECRUITER: Read list of the

two age groups)

____ 18-25

____ 26-34

____ “Neither,” other or refused (terminate)

NOTE TO RECRUITER IN EACH CITY WHERE

FOCUS GROUPS ARE HOSTED:

Recruit for a total of four groups. Two groups will be composed of men ages 18-25; two other groups will be men ages 26-34.

During a typical week, about how many days do you drive at least 10 miles per day? (NOTE TO RECRUITER: read list):

____ Less than once a week (terminate)

____ About once a week (terminate)

____ 2-4 times per week

____ 5 or more times per week

NOTE TO RECRUITER: The next question is an articulation question. What the respondent says is not important; rather, judge his ability and willingness to comment with a specific point-of-view.

In your opinion, what would be the best way to minimize traffic congestion on highways in your area?

____ Articulate

____ Not articulate (terminate)

I’m going to read a series of statements. Please tell me on a scale of 1 to 5 -- where “1” means “that’s just like me” and “5” means “that’s not like me at all,” – how you would rate yourself for each statement. (NOTE TO RECRUITER: Read each statement. OK to repeat and/or clarify rating instructions)

1 2 3 4 5 I have a competitive mind-set about most things I do.

1 2 3 4 5 I consider myself more of a risk-taker compared

to most people.

1 2 3 4 5 I’m the type of person who works hard and plays hard.

1 2 3 4 5 Getting promotions in my job or career is very important

to me.

1 2 3 4 5 If given the opportunity and training, I think it

would be fun to do something edgy, like parachute from a

plane, drive a race car or other thrill-seeking activity

(NOTE TO RECRUITER: Accept if person rates himself “1” or ”2” for at least three of the statements; if not at least three, terminate.)

Now I’ll read three more statements about driving. This time, use the scale of 1 to 5 to tell me how much you agree with the statement. “1” means you totally agree, and “5” means you totally disagree. (NOTE TO RECRUITER: Read each statement. OK to repeat and/or clarify rating instructions)

1 2 3 4 5 In the (city) area, drivers who tend to ignore laws like

speed limits or seat belt laws do so because they think

they can get away with it most of the time.

1 2 3 4 5 In the (city) area, drivers who tend to ignore laws like

speed limits or seat belt laws do so because they think

that’s the way lots of other people drive.

1 2 3 4 5 In the (city) area, drivers who tend to ignore laws like

speed limits or seat belt laws do so because they have

never been caught or ticketed before.

(NOTE TO RECRUITER: Accept if person rates “1” or”2” for at least one of the statements; if not at least one, terminate.)

Do you consider yourself Hispanic or Latino?

____ Hispanic or Latino (take maximum of 3; no minimum quota)

____ Not Hispanic or Latino

____ Refused (terminate)

Do you consider yourself ---- (NOTE TO RECRUITER: read list and check all that apply; OK to repeat list if asked)

____ American Indian or Alaska Native

____ Asian (take maximum of 2; no minimum quota)

____ Black or African American (take maximum of 2; no minimum quota)

____ Native Hawaiian or Other Pacific Islander

____ White

____ Refused (terminate)

Based on your responses, we would like to invite you to participate in a focus group research study about advertising campaign ideas. The group discussion will be about an hour-and-a-half in length, and for your participation, you will receive $75 cash. About 10 others will participate. The meeting will be on (SCHEDULED DATE) at (SCHEDULED START TIME) p.m. It will be at our focus group research facility at (FOCUS GROUP FACILITY ADDRESS/LOCATIONAL INFORMATION).

(NOTE TO RECRUITER: Convey additional appropriate details if respondent is willing to participate)

NHTSA Form 1140 Page 7