CRASH
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 A.5.1.3.15
(01) one year or less
(02-96) actual number of years
(97) not applicable/no previous experience/first time
(99) unknown
16. How many MONTHS have you operated the crash-involved motor vehicle?___ ___ ___
(000) this is the first time A.5.1.3.16
(001) less than or equal to one month
(002-095) actual number of months
(096) 96 months or more
(998) other (specify) __________
(999) unknown
17. How many miles per year do you drive a car or truck? ____ ____ ____ ____ ____
(00001-99995) actual miles
(99996) 99996 or greater miles
(99998) other (specify) ____
(99999) unknown
18. 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
19. 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
20. 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
21. 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
22. How many MONTHS have you operated a street motorcycle? ___ ___ ___
(000) none, do not ride motorcycles
(001) less than or equal to one month
(002-095) actual number of months
(096) 96 months or more
(997) not applicable
(998) other (specify) __________
(999) unknown
IF NEVER OPERATED A MOTORCYCLE, CODE QUESTIONS 23-25 N/A AND GO TO QUESTION 26.
23. 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
24. About how many miles per year do you ride motorcycles? ___ ___ ___ ___ ___
(00001-99995) actual miles A.5.1.3.19
(99996) 99996 or greater miles
(99998) other (specify) ____
(99997) not applicable, do not ride motorcycles
(99999) unknown
25. 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, do not ride motorcycles
(999) unknown
TRIP INFORMATION
26. At what kind of location did you begin your trip today? ___ ___ A.5.1.3.27
(01) home A.5.1.1.27
(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
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?___ __ A.5.1.3.31
(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 had you driven before the crash occurred? ___ ___ ___
(001) one mile or less A..5.1.3.31
(002-095) actual hours
(096) 96 or more
(997) not applicable, had not yet begun trip
(998) other (specify) ___________
(999) unknown
SITUATION
32. Were you distracted by any of the following? ___ ___ A.5.1.3.44
Prior to Recognition Of Critical Event
(01) Attentive or not distracted
(02) Looked but did not see
Distractions
(03) By other occupant(s), (specify):___
(04) By moving object in vehicle (specify): ________
(05) While talking or listening to cellular phone/intercom or short wave radio
(specify location and type of phone):_________
(06) While dialing cellular phone/intercom/short wave radio
(specify location and type of phone): ____________________
(07) While adjusting climate controls
(08) While adjusting radio, cassette, CD (specify): ___________________________________
(09) While using other device/controls integral to vehicle (specify):_____________________
(10) While using or reaching for device/object brought into vehicle (specify): _______________
(11) Sleepy or fell asleep
(12) Distracted by outside person, object, or event (specify): ___________________________
(13) Eating or drinking
(14) Smoking related
(15) While listening or adjusting GPS device
(96) Distracted/inattentive, details unknown
(98) Other, distraction (specify): __________________
(99) Unknown
PRECRASH DATA
33. How many passengers were in your vehicle? ____
(0) none
(1) one
(2) two
(3) three
(4) four or more
(9) unknown
34. How were you operating your vehicle immediately prior to the crash? ___ ___
(00) Stopped in traffic, speed is zero
(01) Moving in a straight line, constant speed
(02) Moving in a straight line, foot off accelerator
(03) Moving in a straight line, braking
(04) Moving in a straight line, accelerating
(05) Turning right, constant speed
(06) Turning right, foot off accelerator
(07) Turning right, braking
(08) Turning right, accelerating
(09) Turning left, constant speed
(10) Turning left, foot off accelerator
(11) Turning left, braking
(12) Turning left, accelerating
(13) Stopped at roadside, or parked
(14) Backing up, in a straight line
(15) Backing up, steering left
(16) Backing up, steering right
(17) Making U-turn right
(18) Making U-turn left
(19) Making Y-turn right
(20) Making Y-turn left
(21) Changing lanes to left
(22) Changing lanes to right
(23) Merging to left
(24) Merging to right
(25) Entering traffic from right shoulder, median, or parked
(26) Entering traffic from left shoulder, median, or parked
(27) Leaving traffic, turn out to right
(28) Leaving traffic, turn out to left
(29) Passing maneuver, passing on right
(30) Passing maneuver, passing on left
(31) Crossing opposing lanes of traffic
(32) Traveling wrong way, against opposing traffic
(36) Collision avoidance maneuver to avoid a different collision
(37) Negotiating a curve, constant speed
(38) Negotiating a curve, foot off accelerator
(39) Negotiating a curve, braking
(40) Negotiating a curve, accelerating
(97) Not applicable
(98) Other, specify: _________________________
(99) Unknown
35. Where were you looking prior to the start of the crash sequence? ___
(1) looking straight ahead
(2) looking right
(3) looking left
(4) looking rearward
(5) looking within or at own vehicle
(8) other (specify) _____________________
(9) unknown
36. In which lane were you traveling? ___
(1) lane one (right curb lane)
(2) lane two
(3) lane three
(4) lane four
(7) not applicable, not in travel lane (parked, on shoulder, etc.)
(8) other (specify) _______
(9) unknown
37. What was your travel speed? ___ ___ A.4.4.2
(00) stopped
(01-95) actual miles per hour
(96) 96 mph or more
(98) other (specify) ______
(99) unknown
38. What collision avoidance actions were you taking (if any)? ___ ___ A.4.4.5.1
Code up to three ___ ___ A.4.4.5.2
(00) none, no avoidance actions ___ ___ A.4.4.5.3
(01) braking
(02) steering
(03) braking and steering
(04) accelerating
(05) steering and accelerating
(06) releasing brakes
(07) honked horn
(09) flashing headlamps
(98) other (specify) ________
(99) unknown
39. Was there any control loss due to weather, roadway or mechanical
problems? ___ ___
(01) no control loss due to weather, roadway or mechanical problems
(02) yes, control loss due to weather
(03) yes, control loss due to mechanical problems
(04) yes, control loss due to both weather and mechanical
(05) yes, control loss due to roadway
(06) yes, control loss due to roadway and weather
(07) yes, control loss due to roadway and mechanical
(08) yes, control loss due to all three
(98) other (specify) ____________
(99) unknown
40. Did the passengers in your vehicle contribute to the crash? ____ A.6.3.3.1
(1) passengers present, but they made no contribution to the crash
(2) yes, passenger activities distracted driver and contributed to the crash
(3) yes, passenger interfered with vehicle control and contributed to the crash
(7) not applicable, no passengers
(8) other, specify:___________
(9) unknown
RECOGNITION/DECISION
41. Where was the motorcycle coming from in relation to you? ___ ___
(00) motorcycle came out of nowhere
(01) 180 degrees opposed (oncoming)
(02) from left front
(03) from left
(04) from left rear
(05) from right front
(06) from right
(07) from right rear
(08) from behind
(97) not applicable/no other vehicle
(98) other (specify) _______
(99) unknown
42. Did anything block the view between you and the motorcycle? ___
(1) no, view was clear
(2) yes, view obstructed by road curvature
(3) yes, view obstructed by roadway grade
(4) yes, view obstructed by roadside objects (shrubs, vehicles, buildings)
(5) yes, other vehicle in blind spot of mirror
(6) yes, view obstructed by other vehicle in traffic
(8) other (specify) ______
(9) unknown
43. Was your view of the motorcycle obscured? ___
(01) no, not obscured
(02) yes, obscured by sun glare
(03) yes, obscured by headlight glare
(04) yes, obscured by other glare (specify) _____
(05) yes, obscured by darkness
(06) yes, obscured by nighttime and color of vehicle
(07) yes, obscured by dust, smoke, smog, fog
(08) yes, obscured by windscreen or eye wear condition (dirt, condensation, etc)
(98) yes, obscured by other (specify) _____
(99) unknown
IMPAIRMENT
44. Do you have any of the following permanent physical conditions?___ ___ A.5.1.3.39.1
(Code up to three; input "01" in remaining responses) ___ ___ A.5.1.3.39.2
(01) no ___ ___ A.5.1.3.39.3
(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
45. At the time of the crash, were you experiencing any of the following?
(Code up to three; input "01" in remaining responses) ___ ___ A.5.1.3.40.1
(01) no ___ ___ A.5.1.3.40.2
(02) fatigue ___ ___ A.5.1.3.40.3
(03) hunger
(04) thirst
(05) elimination urgency
(06) muscle spasm, cramp, itch
(07) headache, minor malaise, fever
(08) siesta syndrome (tired in afternoon)
(97) not applicable
(98) other (specify) _______________
(99) unknown
46. Were you concerned about any of the following issues on the day of the crash?
(Code up to three; input "01" in remaining responses) ___ ___ A.5.1.3.41.1
(01) no problems ___ ___ A.5.1.3.41.2
(02) conflict with friends, relatives, divorce, separation ___ ___ A.5.1.3.41.3
(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
47. 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
48. Did you drink any alcohol or take any drugs or medications today? ___ A.5.1.3.32
(1) no
(2) alcohol use, only
(3) drug/medication use, only
(4) combined alcohol and drug/medication use
(8) other, _________________________________
(9) unknown
The following questions are to be independently verified.
49. Alcohol/drug impairment? ___ A.5.1.3.33
(1) no impairment
(2) not legally impaired
(3) legally impaired
(8) other (specify) _________
(9) unknown
50. Blood alcohol concentration (BAC)? __ __ __ In mg/100ml A.5.1.3.34
Code results
(000) negative BAC
(995) BAC tested, results not known
(996) BAC not tested
(998) other (specify) _______
(999) unknown
51. Source of BAC information? ___ ___ A.5.1.3.35
(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
Time span in hours from crash to BAC collection? ___ ___ A.5.1.3.36
(00) no test done
(01-96) actual hours
(98) other (specify) ______________
(99) unknown
Type of drugs other than alcohol? ____ A.5.1.3.37
(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
Source of drugs other than alcohol? ___ A.5.1.3.38
(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 | Motor Vehicle Driver Questionnaire |
| File Modified | 2007-07-23 |
| File Created | 2007-07-23 |