NHTSA 1109 ATT C5 NCRUSS Observation--Non-Response

A TTACHMENT C5

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 2127-0642. Public reporting for this collection of information is estimated to be approximately 0 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. NHTSA Form 1109

United States Department of Transportation National Highway Traffic Safety Administration

OBSERVATION FORM NON-RESPONSE (3/10/11 Draft)

Form Approved O.M.B. No. 2127-0642 Expiration Date: xxxx National Automotive Sampling System National Child Restraint Use – Special Study

(Site Information)

1. Primary Sampling Unit Number: _____ _____

2. Site Number: _____ _____

3. Observation Number: _______/_______

4. Date of Observation: _______/_______/2011

FOLLOWING ITEMS ARE ONLY OBTAINED BY OBSERVATION – DO NOT CHANGE IF RECEIVE ADDITIONAL DATA

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5. Contact Characteristics

   1. Start Time: _______________

   2. Driver Replies in:

      1. O English

      2. O Spanish

      3. O Other

   3. Contact Status:

      1. O Refused

      2. O Agreed

OBSERVATION INFORMATION (Select one answer for each of the following items)

6. Driver Age

   1. O Young Adult (16-24 years)

   2. O Adult (25-69 years)

   3. O Senior (70+ years)

   4. O Unknown

7. Driver Gender

   1. O Male

   2. O Female

   3. O Unknown

8. Driver Restraint Use

   1. O L-S

   2. O L

   3. O S

   4. O None

   5. O Unknown

9. # Adults/Teens in Vehicle # ____________ O DK

10. # Children (< 9 Yrs.) /Vehicle # _________ O

11. # < 9 Yrs. Unrestrained # ______________ O DK

12. Vehicle Type

    1. O Auto

    2. O Minivan or van

    3. O SUV

    4. O Pick-up truck

    5. O Unknown