CONTROL
MOTOR VEHICLE DRIVER QUESTIONNAIRE
1. Case Number ____________ 2. Vehicle Number ______ A. 4.3.1
BACKGROUND INFORMATION
3. How old are you? ___ ___ A.5.1.3.3
Code actual age in years
(99) unknown
4. What state/country issued your current driver's license? _____ A.5.1.3.4
(1) no license
(2) California
(3) other State (list) ________
(4) Canada
(5) Mexico
(6) military
(7) not applicable
(8) other (describe) ____________
(9) unknown
5. What kind of operator's license is it? ___ ___ A.5.1.3.5.1
(Code up to 4; input "00" in remaining responses) ___ ___ A.5.1.3.5.2
(01) no license held ___ ___ A.5.1.1.5.3
(02) learner's permit, only ___ ___ A.5.1.1.5.4
(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, no license required
(98) other (describe) ___________
(99) unknown
6. What year was/were the license(s) issued? __ __ __ __ A.5.1.3.6.1
(Listed in same order as licenses above __ __ __ __ A.5.1.3.6.2
(9997) not applicable __ __ __ __ A.5.1.3.6.3
(9999) unknown __ __ __ __ A.5.1.3.6.4
7. Does your license qualify you to operate this motor vehicle? ____ A.5.1.3.7
(1) no
(2) yes
(7) not applicable
(9) unknown
8. Are you of Hispanic or Latino origin? ____
(0) refused to answer
(1) no
(2) yes
(8) other (describe) __________
(9) unknown
9. 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
10. What is your height? ___ft. ___ ___ in. A.5.1.3.9
(9/99) unknown
11. What is your weight? ___ ___ ___lbs. A.5.1.3.10
(999) unknown
12. Gender ___
(1) male
(2) female
(9) unknown
13. How much formal education have you had? ___ ___ A.5.1.3.11
(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
14. What is your current occupation? ___ ___ A.5.1.3.13
(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
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 miles per year do you drive a car or truck? ____ ____ ____ ____ ____
(00000) none
(00001-99995) actual miles
(99996) 99996 or greater miles
(99998) other (specify) ____
(99999) unknown
17. What kind of driver training have you had? ___ ___ A.5.1.3.20
(01) no training
(02) self taught
(03) taught by friends or family
(03) official driver training class
(04) voluntary drivers education
(05) compulsory drivers education
(06) professional training for commercial license
(07) compulsory motor vehicle training ordered by judge/police/etc.
(98) other (specify) ___________
(99) unknown
18. How many moving traffic violations/convictions have you had in the previous 5 years?
Code the total number of moving traffic convictions – any vehicle ___ ___ A.5.1.3.24
(00) none
(99) unknown
19. Of those how many were motorcycle moving traffic crashes? ___ ___ A.5.1.3.25
Code the total number of previous motorcycle moving traffic crashes
(00) none
(99) unknown
20. Of those how many were car or truck moving violation crashes? ___ ___ A.5.1.3.26
Code the total number of previous car or truck moving traffic crashes
(00) none
(99) unknown
21. How many MONTHS have you operated a street motorcycle? ___ ___ ___
(001) less than or equal to one month
(002-095) actual number of months
(096) 96 months or more
(997) not applicable, never operate motorcycle
(998) other (specify) __________
(999) unknown
IF NEVER OPERATED A MOTORCYCLE, CODE QUESTIONS 22-24 N/A AND GO TO QUESTION 25.
22. What is the average number of days per year you ride motorcycles? ___ ___ ___
(001-365) Actual number of days per year A.5.1.3.18
(997) not applicable
(998) other __________________________________
(999) unknown
23. About how many miles per year do you ride motorcycles? ___ ___ ___ ___ ___
(00000) none A.5.1.3.19
(00001-99995) actual miles
(99996) 99996 or greater miles
(99998) other (specify) ____
(99997) not applicable
(99999) unknown
24. If 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 ___ ___ ___ % A.5.1.3.21.1
Basic transportation ___ ___ ___ % A.5.1.3.21.2
100%
(997) not applicable, never ride motorcycles
(999) unknown
TRIP INFORMATION
25. At what kind of location did you begin your trip today? ___ ___ A.5.1.3.27
(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
26. How many passengers are in your vehicle? ____
(0) none
(1) one
(2) two
(3) three
(4) four or more
(9) unknown
27. What was your trip destination? ___ ___ A.5.1.3.28
(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.5.1.3.29
Code the number of miles
(001) one mile or less
(002-995) actual number of miles
(996) 996 miles or greater
(997) not applicable
(999) unknown
29. How frequently do you travel this road on/in any vehicle? ___ A.5.1.3.30
(01) first time
(02) daily use, i.e., once or more per day
(03) weekly use, i.e., once or more per week
(04) monthly use, i.e., once or more per month
(05) quarterly, i.e., once or more per quarter
(06) annually, i.e., once or more per year
(07) less than annually
(99) unknown
30. How many hours have you been driving today since your 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
31. How many miles have you been driving since your 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
IMPAIRMENT
32. Do you have any of the following permanent physical conditions? ___ ___
(Code up to three; input "01" in remaining responses)
(01) no
(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
33. Are you experiencing any of the following? ___ ___
(Code up to three; input "01" in remaining responses) ___ ___
(01) no ___ ___
(02) fatigue ___ ___
(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
34. Are you concerned about any of the following issues today?
(Code up to three; input "01" in remaining responses) ___ ___
(01) no problems ___ ___
(02) conflict with friends, relatives, divorce, separation ___ ___
(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
35. 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
36. Did you drink any alcohol or take any drugs or medications today? ___
(1) no
(2) alcohol use, only
(3) drug/medication use, only
(4) combined alcohol and drug/medication use
(8) other, _________________________________
(9) unknown
37. Type of drugs other than alcohol? ___
(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
38. Source of drugs other than alcohol? ___
(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 | Motor Vehicle Driver Questionnaire |
| File Modified | 2007-06-08 |
| File Created | 2007-06-08 |