NHTSA 1107 ATT C3-NCRUSS Interview-Occuptants by SP

A TTACHMENT C3

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 4 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 1107

United States Department of Transportation National Highway Traffic Safety Administration

INTERVIEW FORM OCCUPANTS BY SP (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

1. PSU # ____ ____ 2. Site # ____ ____ 3. Observation # ____ ____ 4. Date of Observation ____ ____/____/2011

5. How many passengers are <9 yrs. of age? ______ 6. In what seats are they sitting? (Circle correct columns below)

Questions (Ask driver)	Attributes	12 Middle	13 Right	21 Left	22 Middle	23 Right	31 Left	32 Middle	33 Right	Other _______
5. What is your relationship to the passenger in SP __________? (Ask Questions #5 through #14 for the first child in the vehicle; repeat for each additional child <9 years)	Parent (P) Spouse (Sp) Grandparent (GP) Sibling (Si) Aunt/Uncle (A/U) OT Relative (Rel) Non-Rel (Non) Don’t Know (DK) Refused (Ref) Didn’t Ask (DA)	O P O Sp O GP O S O A/U O Rel O Non O DK O Ref O DA	O P O Sp O GP O S O A/U O Rel O Non O DK O Ref O DA	O P O Sp O GP O S O A/U O Rel O Non O DK O Ref O DA	O P O Sp O GP O S O A/U O Rel O Non O DK O Ref O DA	O P O Sp O GP O S O A/U O Rel O Non O DK O Ref O DA	O P O Sp O GP O S O A/U O Rel O Non O DK O Ref O DA	O P O Sp O GP O S O A/U O Rel O Non O DK O Ref O DA	O P O Sp O GP O S O A/U O Rel O Non O DK O Ref O DA	O P O Sp O GP O S O A/U O Rel O Non O DK O Ref O DA
6. What is the gender of this passenger?	Male Female	O M O F	O M O F	O M O F	O M O F	O M O F	O M O F	O M O F	O M O F	O M O F
7. Is this passenger of Hispanic or Latino origin?	Yes No Don’t Know (DK) Refused (Ref) Didn’t Ask (DA)	O Yes O No O DK O Ref O DA	O Yes O No O DK O Ref O DA	O Yes O No O DK O Ref O DA	O Yes O No O DK O Ref O DA	O Yes O No O DK O Ref O DA	O Yes O No O DK O Ref O DA	O Yes O No O DK O Ref O DA	O Yes O No O DK O Ref O DA	O Yes O No O DK O Ref O DA
8. Which of the following best describes this passenger’s race? (All that apply)	--White (WH) --Black or African American (BA) --Asian (AS) --Am. Indian/ Alaska Native (AI) --Native Hawaiian/ Other Pacific Islander (NH) --Other (OT) --Don’t Know (DK) --Refused (Ref) --Didn’t Ask (DA)	WH BA AS AI NH OT DK Ref DA	WH BA AS AI NH OT DK Ref DA	WH BA AS AI NH OT DK Ref DA	WH BA AS AI NH OT DK Ref DA	WH BA AS AI NH OT DK Ref DA	WH BA AS AI NH OT DK Ref DA	WH BA AS AI NH OT DK Ref DA	WH BA AS AI NH OT DK Ref DA	WH BA AS AI NH OT DK Ref DA
9. What is the age of the passenger in SP ________?	Age (A) Don’t Know (DK) Refused (Ref) Didn’t Ask (DA) Age Range (R)	A ____ O DK O Ref O DA R _____	A ____ O DK O Ref O DA R _____	A ____ O DK O Ref O DA R _____	A ____ O DK O Ref O DA R _____	A ____ O DK O Ref O DA R _____	A ____ O DK O Ref O DA R _____	A ____ O DK O Ref O DA R _____	A ____ O DK O Ref O DA R _____	A ____ O DK O Ref O DA R _____
10. (If DK), What is the age range? 1. Under 1 year 2. 1-3 years 3. 4-7 years 4. 8-9 years
11. How much does this child weigh? If DK, ask: 12. What is your best estimation? Does this child weigh <20 lbs, etc.?	Lbs. (L) < 20 lbs 20-29 lbs 30-39 lbs 40-60 lbs > 60 lbs Don’t Know (DK) Refused (Ref) Didn’t Ask (DA)	L _____ O < 20 O 20+ O 30+ O 40+ O > 60 O DK O Ref O DA	L _____ O < 20 O 20+ O 30+ O 40+ O > 60 O DK O Ref O DA	L _____ O < 20 O 20+ O 30+ O 40+ O > 60 O DK O Ref O DA	L _____ O < 20 O 20+ O 30+ O 40+ O > 60 O DK O Ref O DA	L _____ O < 20 O 20+ O 30+ O 40+ O > 60 O DK O Ref O DA	L _____ O < 20 O 20+ O 30+ O 40+ O > 60 O DK O Ref O DA	L _____ O < 20 O 20+ O 30+ O 40+ O > 60 O DK O Ref O DA	L _____ O < 20 O 20+ O 30+ O 40+ O > 60 O DK O Ref O DA	L _____ O < 20 O 20+ O 30+ O 40+ O > 60 O DK O Ref O DA
13. Driver: How tall is this child? If DK, ask: 14. What is your best estimation? Is this child <20”, etc?	Feet (Ft) Inches (In) < 20” 20-29” 30-36” (2.5-3’) 37-49” (3-4’) 50-56” (4-4.75’) >56” Don’t Know (DK) Refused (Ref) Didn’t Ask (DA)	Ft_____ In_____ O < 20 O 20+ O 30+ O 37+ O 50+ O > 56 O DK O Ref O DA	Ft_____ In_____ O < 20 O 20+ O 30+ O 37+ O 50+ O > 56 O DK O Ref O DA	Ft_____ In_____ O < 20 O 20+ O 30+ O 37+ O 50+ O > 56 O DK O Ref O DA	Ft_____ In_____ O < 20 O 20+ O 30+ O 37+ O 50+ O > 56 O DK O Ref O DA	Ft_____ In_____ O < 20 O 20+ O 30+ O 37+ O 50+ O > 56 O DK O Ref O DA	Ft_____ In_____ O < 20 O 20+ O 30+ O 37+ O 50+ O > 56 O DK O Ref O DA	Ft_____ In_____ O < 20 O 20+ O 30+ O 37+ O 50+ O > 56 O DK O Ref O DA	Ft_____ In_____ O < 20 O 20+ O 30+ O 37+ O 50+ O > 56 O DK O Ref O DA	Ft_____ In_____ O < 20 O 20+ O 30+ O 37+ O 50+ O > 56 O DK O Ref O DA