Form NHTSA Form 1130 NHTSA Form 1130 Survey

OMB Control No. 2127-xxxx

Expiration Date xx-xx-xxxx

Removable Adhesive Band

The National Highway Traffic Safety Administration and the (NAME OF STATE MOTORCYCLE SAFETY PROGRAM), are undertaking an extensive study of motorcycle safety. As part of this study, we are developing a profile of (NAME OF STATE) on-street motorcyclists’ riding habits, riding experience, and driving records. You can help us by filling out the following questionnaire.

All information will remain private and will not be used for commercial purposes.

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 5 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

1. How much street riding experience do you have? (Check One)

 Just beginning (less than 500 miles)  More than a year and 500 to 2,000 miles

 Less than a year and 500 to 2,000 miles  More than a year and over 2,000 miles

 Less than a year and over 2,000 miles If more than a year, please fill in number of years:            

2. How many on-street miles have you ridden in the past year? _____________ miles

3. Do you own a street motorcycle/motor scooter?  Yes  No (Skip to Question 4)

3.a What size is it? ____________CC

3.b What category is it?  Sportbike  Cruiser  Touring  Off-Road  Other__________________

4. What is your primary reason for riding?  Commuting  Recreation  Other _________________________

5. When riding a motorcycle, how often do you: Always Frequently Sometimes Rarely Never

a. Wear a DOT-compliant helmet?     

b. Ride above the speed limit?     

c. Wear a protective jacket and heavy shoes?     

d. Ride with organized groups?     

e. Ride within 2 hours of drinking an alcoholic beverage?     

f. Split lanes in heavy traffic?     

6. During the past year, have you had at least one drink of any alcoholic beverage?  Yes  No

7. Have you ever been involved in an on-street motorcycle/motor scooter crash?  Yes  No (Skip to Question 9)

8. How long has it been since your most recent crash? ______ Years and _____ Months

9. How many minor incidents (minor or no injury/damage) or close-calls have you experienced in the past year?

 None  1  2  3  4  5  Other _____________

10. Which of the motorcycle training courses have you completed? (Check as many as apply)

 Motorcycle Safety Foundation  (STATE PROGRAM)  Racing Skills

 Military Program (Which Service?) ______________________  Other ______________________  None

10a. If you have not completed a motorcycle training course, have you tried to enroll in one?  Yes  No

11. Gender:  M  F 12. Date of Birth (Mo/Day/Year) ___ ___ / ___ ___ / ___ ___

13. Driver’s License Number: _____________________________ State: ___________________________________

14. Do you have a motorcycle license/endorsement?  Yes  No

15. Learner’s permit?  Yes  No

THANK YOU for participating in this survey. Location _______________________________ Date _______________

NHTSA Form 1130

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