CRASH
Motorcycle Passenger Questionnaire
1. Case Number ____________ 2. MC Passenger Number ____ A.5.1.2.1
BACKGROUND INFORMATION
3. How old are you? ___ ___ A.5.1.2.3
Code actual age in years
(99) unknown
4. Where did you get your current driver's license? _____ A.5.1.2.4
(1) no license
(2) California
(3) other State (list) ________
(4) Canada
(5) Mexico
(6) military
(8) other (describe) ____________
(9) unknown
5. What kind of operator's license is it? ___ ___ A.5.1.2.5.1
(Code up to 4; input "97" in remaining responses) ___ ___ A.5.1.2.5.2
(01) no license held ___ ___ A.5.1.2.5.3
(02) learner's permit, only ___ ___ A.5.1.2.5.4
(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
(98) other (describe) ___________
(99) unknown
6. What year was/were the license(s) issued? __ __ __ __ A.5.1.2.6.1
(Listed in same order as licenses above __ __ __ __ A.5.1.2.6.2
(9997) - not applicable, no license __ __ __ __ A.5.1.2.6.3
(9999) - unknown __ __ __ __ A.5.1.2.6.4
7. Are you of Hispanic or Latino origin? ____
(0) refused to answer
(1) no
(2) yes
(8) other (describe) __________
(9) unknown
8. 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
9. What is your height? ___ft. ___ ___ in. A.5.1.1.9
(9/99) unknown
10. What is your weight? ___ ___ ___lbs. A.5.1.1.10
(999) unknown
11. Gender ___ A.5.1.1.11
(1) male
(2) female
(9) unknown
12. How much formal education have you had? ___ A.5.1.2.12
(1) no formal schooling
(2) less than high school diploma
(3) high school diploma or GED
(4) partial college/university
(5) college/university graduate
(6) graduate school, advanced degree, professional degree
(7) specialty/technical school
(8) other (specify) ___________
(9) unknown
13. What is your current occupation? ___ ___ A.5.1.2.13
(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
14. Are you married? ___ ___ D.5.2.1.2.4
(01) not married
(02) single
(03) married
(04) separated
(05) divorced
(06) widowed
(07) cohabitating
(98) other (specify)
(99) unknown
15. How many children do you have? ___ D.5.2.1.2.5
(0) none
(1) one
(2) two
(3) three
(4) four
(5) five
(6) six
(7) more than six
(9) unknown
RIDING/DRIVING EXPERIENCE
16. How many YEARS have you been driving any kind of ___ ___ A.5.1.2.15
motor vehicle?
(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
If no driving experience of any kind, skip to Question 27.
17. How many MONTHS have you operated a street motorcycle ___ ___ ___ A.5.1.2.16
(001) less than or equal to one month
(002-095) actual number of months
(096) 96 months or more
(997) not applicable, never operated motorcycle
(998) other (specify) __________
(999) unknown
18. What is the average number of days per year you operate motorcycles? __ __ __A.5.1.2.18
(001-365) Code actual number of days per year
(997) not applicable, never operate motorcycle
(999) unknown
19. About how many miles per year do you operate ___ ___ ___ ___ ___ A.5.1.2.19
motorcycles?
(00000) none
(00001-99995) actual miles
(99996) 99996 or greater miles
(99998) other (specify) ____
(99999) unknown
20. How many miles per year do you drive a car or truck? ____ ____ ____ ____ ____
(00000) None, do not drive car or truck
(00001-99995) actual miles
(99996) 99996 or greater miles
(99998) other (specify) ____
(99999) unknown
21. What kind of motorcycle training have you had? ___ A.5.1.2.20
(00) none
(01) self taught
(02) taught by family or friends
(03) special voluntary motorcycle training for road riding
(04) special compulsory motorcycle training for road riding
(05) professional training for competition license
(06) advanced training
(07) compulsory motorcycle training ordered by judge/police/etc.
(98) other (specify) __________________
(99) unknown
22. Have you had any car or truck driver training? ___ ___
(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
23. How old were you when you first began to ride a motorcycle? ____ ____
Code actual age
(00) never rode before, or rarely ever rides
(98) other (specify) _______
(99) unknown
24. Were there years in which you did not ride a motorcycle? ____
(1) no
(2) yes
(7) not applicable, never before rode
(8) other (specify) ______
(9) unknown
25. How many years before you started riding again? ____ ____
(00) never stopped riding
(01-96) actual number of years
(97) not applicable, never before rode
(98) other _____________
(99) unknown
26. When 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.5.1.2.21.1
Basic transportation ___ ___ ___ % A.5.1.2.21.2
100%
(000) first time use
(997) not applicable
(999) unknown
27. How much experience do you have riding as a passenger on motorcycles? ___ A.5.1.2.22
(0) never rode as a passenger before
(1) very little experience
(2) moderate experience
(3) extensive experience
(8) other __________________________________________
(9) unknown
SITUATION
28. Where were you seated prior to the crash? ___ A.5.1.2.42
(1) immediately behind the motorcycle rider
(2) immediately in front of the motorcycle rider
(3) behind passenger in location 1
(4) behind passenger in location 2
(5) behind passenger in location 3
(6) dismounting, jumping to side
(7) not applicable, unseated prior to the crash
(8) other (specify) _____________
(9) unknown
29. Where were you seated at the time of collision? ___ ___ A.5.1.2.43.1
(01) normal, straddle seated behind rider
(02) riding with both legs on left side of motorcycle
(03) riding with both legs on right side of motorcycle
(04) straddle seated on pillion behind rider
(05) straddle seated on tank ahead of rider
(06) in sidecar
(07) straddle seated, behind rider, facing rear
(98) other (specify) _____________
(99) unknown
30. Did any of your actions contribute to the crash? ___ A.6.3.2.1
(01) yes, passenger weight contributed to loss of control during evasive action
(02) yes, passenger lost hold or fell and contributed to rider loss of control
(03) yes, passenger interfered with motorcycle balance, caused rider loss of control
(04) yes, passenger interfered with motorcycle controls and contributed to crash
(05) yes, passenger’s lower extremities entrapped in rear suspension or wheel and contributed to crash
(06) yes, passenger action distracted motorcycle rider and contributed to crash,
specify: ______________________________
(97) not applicable, no action by passenger contributed to crash.
(98) other passenger action that contributed to crash, specify: ___________
(99) unknown
PROTECTIVE CLOTHING/GEAR AT TIME OF CRASH
31. What kind of clothing was on your upper body? ____ A.5.3.2.1
(0) none
(1) light cloth garment, i.e., thin cotton
(2) medium cloth garment, i.e., denim, nylon
(3) heavy cloth garment, i.e., imitation leather
(4) leather garment
(5) Kevlar
(8) other (specify) _________________________
(9) unknown
32. Was this upper body clothing motorcycle-oriented? ____ A.5.3.2.2
(1) no
(2) yes
(7) not applicable/no clothing
(8) other (specify) ________
(9) unknown
33. What kind of clothing was on your lower body? ____ A.5.3.2.3
(0) none
(1) light cloth garment, i.e., thin cotton
(2) medium cloth garment, i.e., denim, nylon
(3) heavy cloth garment, i.e., imitation leather
(4) leather garment
(5) Kevlar
(8) other (specify) ____________
(9) unknown
34. Was this lower body clothing motorcycle-oriented? ____ A.5.3.2.4
(1) no
(2) yes
(7) not applicable/no clothing
(8) other (specify) ________
(9) unknown
35. Were you wearing an inflatable safety vest? _____
(1) no
(2) yes
(8) other (specify) _______
(9) unknown
36. What kind of shoes or boots were you wearing? ____ A.5.3.2.5
(1) no shoes or boots, barefoot
(2) light sandal
(3) medium street shoe, loafer
(4) athletic, training shoe
(5) heavy shoe or boot
(6) reinforced work boot or motorcycle boot
(8) other (specify) _______
(9) unknown
37. Did this footwear go up over your ankle?
(1) no
(2) yes
(7) not applicable, no footwear worn
(8) other, specify __________________
(9) unknown
38. Was the footwear motorcycle-oriented? ____ A.5.3.2.6
(1) no
(2) yes
(7) not applicable, no footwear worn
(9) unknown
39. What kind of gloves were you wearing? ____ A.5.3.2.7
(0) none
(1) light cloth garment, i.e., thin cotton
(2) medium cloth garment, i.e., denim, nylon
(3) heavy cloth garment, i.e., imitation leather
(4) leather garment
(5) Kevlar
(8) other (specify) __________________
(9) unknown
40. Are the gloves motorcycle-oriented? ____ A.5.3.2.8
(1) no
(2) yes, full fingered
(3) yes, shorties
(7) not applicable, no gloves worn
(8) other (specify) ______
(9) unknown
41. Is any of this clothing retroreflective? _____
Code up to 3 responses _____
(1) no retroreflective clothing or gloves _____
(2) upper body (shirt/jacket/vest)
(3) lower body (pants/ shorts)
(4) gloves
(5) special arm bands, or similar items
(7) not applicable, no clothing or gloves
(8) other (specify) _________
(9) unknown
42. What is the clothing color of the following?
Upper body clothing ___ ___ D.5.3.2.6.1
Lower body clothing ___ ___ D.5.3.2.6.2
Footwear ___ ___ D.5.3.2.6.3
Gloves ___ ___ D.5.3.2.6.4
(01) no dominating color, multi-colored
(02) white
(03) yellow
(04) black
(05) red
(06) blue
(07) green
(08) silver
(09) orange
(10) brown
(11) purple
(12) gold
(13) grey
(97) not applicable/no clothing
(98) other (specify) ________
(99) unknown
43. What kind of eye protection were you wearing at the time of
the crash? ____ ____ A.5.1.1.14/A 5.1.2.14
(01) none
(02) non-prescription clear glasses
(03) prescription clear glasses
(04) non-prescription sunglasses
(05) prescription sunglasses
(06) goggles, non-prescription
(07) goggles, prescription
(08) industrial safety glasses
(98) other (specify) ____________
(99) unknown
44. What color was the eye coverage lens? ____ A.5.3.2.10
(1) clear
(2) green
(3) grey, smoke
(4) amber, yellow
(5) blue
(6) reflective (any color)
(7) not applicable, not wearing eye coverage
(8) other (specify) __________________________
(9) unknown
HELMET DATA
45. Were you wearing a helmet? ____ A.5.3.2.11
(1) no
(2) yes
(3) helmet available but not used
(8) other (specify) ______
(9) unknown
46. What is your reason for not wearing a helmet? D.5.2.1.2.13 ___ ___
(01) not required by law
(02) no expectation of accident involvement
(03) helmets too expensive
(04) helmets are inconvenient and uncomfortable
(05) helmets reduce traffic awareness, limit hearing and vision
(06) helmets ineffective in reducing head injury
(07) helmets cause neck injury
(08) helmets can not be used, physical or religious reasons
(09) do not own a helmet
(10) forgot to bring helmet today
(97) not applicable, rider always wears a helmet
(98) other (*describe, 80 characters) ________________________
(99) unknown
If No Helmet was worn, go to Question 59
47. Was your helmet properly adjusted? ____ A.5.3.2.12
(1) no
(2) yes
(7) not applicable, no helmet
(8) other (specify) ______
(9) unknown
48. Was your helmet securely fastened? ____ A.5.3.2.13
(1) no
(2) yes
(7) not applicable, no helmet
(8) other (specify) ______
(9) unknown
49. What type of helmet is it? ____ A.5.3.2.14
(1) not a motorcycle helmet
(2) half/police motor vehicle, motorcycle helmet
(3) open face motor vehicle, motorcycle helmet
(4) full face motor vehicle, motorcycle helmet
(5) novelty helmet
(7) not applicable, not helmet
(8) other (specify)
(9) unknown
50. What is the type of coverage? ___ ___ A.5.3.2.15
(11) partial coverage
(12) full coverage
(13) full facial, integral chin bar but no face shield
(14) full facial, removable chin bar
(15) full facial, retractable chin bar
(16) full facial coverage, integral chin bar and face shield
(17) wrap around face shield
(18) bubble type face shield
(19) visor/face shield combo
(97) not applicable/no helmet
(98) other (specify)
(99) unknown
51. What is the predominant color of your helmet? ___ ___ A.5.3.2.16
(01) no dominating color, multi-colored
(02) white
(03) yellow
(04) black
(05) red
(06) blue
(07) green
(08) silver, grey
(09) orange
(10) brown, tan
(11) purple
(12) gold
(13) chrome, metallic
(97) not applicable/no helmet
(98) other (specify) ________
(99) unknown
52. What is the color of the face shield? ____ A.5.3.2.17
(1) clear
(2) green
(3) grey, smoke
(4) amber, yellow
(5) blue
(6) reflective (any color)
(7) not applicable/no face shield
(8) other (specify) ________
(9) unknown
53. Do you own this helmet? ____ A.5.3.2.18
(1) no
(2) yes
(7) not applicable, no helmet
(8) other (specify) ______
(9) unknown
54. How well does this helmet fit? ____ A.5.3.2.19
(1) acceptable fit
(2) too large, too loose
(3) too small, too tight
(7) not applicable/no helmet
(8) other (specify) ____________________
(9) unknown
55. What percentage of time do you wear your helmet? ___ ___ ___ % A.5.3.2.20
(001-100) percent helmet worn
(997) not applicable/no helmet
(999) unknown
56. Under what conditions do you usually wear your helmet? ___ A.5.3.2.21.1
(code all that apply; input "0" for remaining responses) ___ A.5.3.2.21.2
(1) never uses helmet ___ A.5.3.2.21.3
(2) long trips ___ A.5.3.2.21.4
(3) highway traffic
(4) in adverse weather
(5) never in hot weather
(6) always
(7) not applicable/no helmet
(8) other (specify) __________
(9) unknown
57. Was helmet retained in place on head during crash? ____ A.5.3.2.30
(1) no, helmet ejected from head during pre-crash time period
(2) no, helmet ejected from head during crash
(3) no, helmet ejected from head after collision
(4) yes, helmet retained in place to completion of accident events
(5) yes, helmet moved on head but was retained
(7) not applicable/no helmet
(8) other (specify)
(9) unknown
IMPAIRMENT
58. Do you have any of the following permanent physical conditions?
(indicate all that apply; input "01" in remaining responses) ___ ___ A.5.1.2.39.1
(01) no ___ ___ A.5.1.2.39.2
(02) vision reduction or loss ___ ___ A.5.1.2.39.3
(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
59. At the time of the crash, were you experiencing any of the following?
(indicate all that apply; input "01" in remaining responses) ___ ___ A.5.1.2.40.1
(01) no ___ ___ A.5.1.2.40.2
(02) fatigue ___ ___ A.5.1.2.40.3
(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
60. Were you concerned about any of the following issues on the day of the crash?
(indicate all that apply; input "01" in remaining responses) ___ ___ A.5.1.2.41.1
(01) no problems ___ ___ A.5.1.2.41.2
(02) conflict with friends, relatives, divorce, separation ___ ___ A.5.1.2.41.3
(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
61. 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
62. Did you drink any alcohol or take any drugs or medications today? ___ A.5.1.2.32
(1) no
(2) alcohol use, only
(3) drug/medication use, only
(4) combined alcohol and drug/medication use
(8) other, _________________________________
(9) unknown
Independently determine following questions
63. Alcohol/drug impairment? ___ A.5.1.2.33
(1) no impairment
(2) not legally impaired
(3) legally impaired
(8) other (specify) _________
(9) unknown
64. Blood alcohol concentration (BAC)? __ __ __ mg/100ml A.5.1.2.34
Code results
(000) negative BAC
(995) BAC tested, results not known
(996) BAC not tested
(998) other (specify) _______
(999) unknown
65. Source of BAC information? ___ A.5.1.2.35
(01) not tested
(02) tested, results not available
(03) breath testing
(04) blood test
(05) urine test
(06) unknown if tested
(07) tested, results unknown
(98) other (specify) _________
(99) unknown source
66. Time span from crash to BAC collection? ___ ___ hours A.5.1.2.3
(00) no test done
(01-96) actual hours
(98) other (specify) ______________
(99) unknown
67. Type of drugs other than alcohol? ___ A.5.1.2.37
(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
68. Source of drugs other than alcohol? ___ A.5.1.2.38
(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 | Motorcycle Passenger Questionnaire |
| File Modified | 2007-07-23 |
| File Created | 2007-07-23 |