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 7 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 1108
United States Department of Transportation National Highway Traffic Safety Administration
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INTERVIEW FORMRESTRAINTS(5/11/11 Draft) |
Form Approved O.M.B. No. 2127-0642 Expiration Date: 3/31/14
National Automotive Sampling System National Child Restraint Use – Special Study |
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__ 12 13 (1st row: ___, middle, right) 21 22 23 (2nd row: left; middle, right) 31 32 33 (3rd row: left; middle, right) Other _______________________________ |
1 Scale: 1-------2-------3------4------5 2 O DK 3 O Refused 4 O DA (Not Confident) (Very Confident) |
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1O CRS, 2 O Booster or Other Child Restraint, 3 O SB, 4 O Unrestrained (U) (If 1-2, continue; if 3-4, skip to Q17.)
For the child restraint in SP ___:
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1 _______________________________ 2 O DK 3 O Refused 4 O DA |
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1 Yrs _________ 2 Months _______ 3 O DK 4O Refused 5 O DA |
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1 O New 2 O Used 3 O DK 4 O Refused 5 O DA |
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(If “Yes” continue; otherwise, skip to Q14) |
1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
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(If “Yes” continue; otherwise, skip to Q14) |
1 Yrs _________ 2 Months _______ 3 O DK 4O Refused 5 O DA |
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1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
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1 Scale: 1-------2-------3------4------5 2 O DK 3 O Refused 4 O DA (Not Confident) (Very Confident) |
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1 O Self 2 O Joint w/other 3 O Partner/spouse/significant other 4 O Parent or other family member 5 O Friend or neighbor 6 O Child 7 O CPST 8 O DK 9 O Refused 10 O DA 11 O Other __________________________________________ |
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FOR BELT POSITIONING BOOSTER SEATS (BPB), SKIP TO Q17; OTHERWISE CONTINUE |
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1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
TETHERS |
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1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
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1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
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(Skip to Q25) |
1 O DK about it 2 O Didn’t think it was important 3 O DK how to use it 4 O Too hard to use 5 O RF seat 6 O Over weight limit 7 O Can’t find 8 O Refused 9 O DA 10 O Other: __________________ |
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1 O Law 2 O Safer 3 O Instructions 4 O DK 5 O Refused 6 O DA 7 O Other: __________________ |
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(If any item from 3-10 is answered, Skip to Q23) |
1 O Self 2 O Joint w/other 3 O Partner/spouse/significant other 4 O Parent or other family member 5 O Friend or neighbor 6 O CPST 7 O DK 8 O Refused 9 O DA 10 O Other: ____________ |
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Very Easy, how difficult or easy did you find it to:
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1---------2---------3--------4--------5 (Very Difficult) (Very Easy) 1--1 Scale #: ____________ 2 O DK 3 O Refused 4 O DA 2--1 Scale #: ____________ 2 O DK 3 O Refused 4 O DA |
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(If “Yes” continue; otherwise, skip to Q25) |
1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
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1 Scale #: _______________ 2 O DK 3 O Refused 4 O DA |
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1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
UPPER STRAPS & ANCHORS |
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1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
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1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
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(Skip to Q36) |
1 O DK about it 2 O Didn’t think it was important 3 O DK how to use it 4 O Too hard to use 5 O RF seat 6 O Over weight limit 7 O Can’t find 8 O Refused 9 O DA 10 O Other: __________________ |
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1 O Law 2 O Safer 3 O Instructions 4 O DK 5 O Refused 6 O DA 7 O Other: __________________ |
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(If any item from 3-10 is answered, Skip to Q32 ) |
1 O Self 2 O Joint w/other 3 O Partner/spouse/significant other 4 O Parent or other family member 5 O Friend or neighbor 6 O CPST 7 O DK 8 O Refused 9 O DA 10 O Other ______ |
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1---------2---------3--------4--------5 (Very Difficult) (Very Easy)
1--1 Scale #: ___________ 2 O DK 3 O Refused 4 O DA 2--1 Scale #: ___________ 2 O DK 3 O Refused 4 O DA |
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(If “Yes” continue; otherwise, skip to Q34) |
1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
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1 Scale #: ___________ 2 O DK 3 O Refused 4 O DA |
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1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
BOTH |
(Skip to Q39) |
1 O Extra secureness or safety 2 O Believed it was necessary 3 O DK 4 O Refused 5 O DA 6 O Other: _________ |
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1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
SEAT BELT |
(Skip to Q43) |
1 O DK about it 2 O Didn’t think it was important 3 O DK how to use it 4 O Too hard to use 5 O RF seat 6 O Over weight limit 7 O Can’t find 8 O Refused 9 O DA 10 O Other: __________________ |
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1 O Law 2 O Safer 3 O Instructions 4 O DK 5 O Refused 6 O DA 7 O Other: __________________ |
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(If any item from 3-10 is answered, Skip to Q41) |
1 O Self 2 O Joint w/other 3 O Partner/spouse/significant other 4 O Parent or other family member 5 O Friend or neighbor 6 O CPST 7 O DK 8 O Refused 9 O DA 10 O Other ______ |
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1---------2---------3--------4--------5 (Very Difficult) (Very Easy)
1--1 Scale #: ___________ 2 O DK 3 O Refused 4 O DA 2--1 Scale #: ___________ 2 O DK 3 O Refused 4 O DA |
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1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
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1 Scale #: ___________ 2 O DK 3 O Refused 4 O DA |
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1. Tether Anchor? 1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA 2. Lower Anchors (LA)? 1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA 3. Seat Belt (SB) 1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
PREFER |
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1 O LA 2 O SB 3 O Both 4 O DK 5 O Refused 6 O DA |
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1 O LA 2 O SB 3 O Both 4 O DK 5 O Refused 6 O DA |
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1 O Never have 2 O Short trip 3 O Child unbuckled self 4 O No seat/booster in vehicle 5 O Forgot to check 6 O Too many passengers in the vehicle 7 O Child does not cooperate 8 O Don't know 9 O Refused 10 O DA 11 O Other ________________ |
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1 O Male 2 O Female |
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1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA |
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1 O White 2 O Black or African American 3 O Asian 4 O Native Hawaiian/Other Pacific Islander 5 O American Indian/Alaska Native 6 O Refused 7 O DA 8 O Other: ___________________________ |
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1 Years: _____________ 2 O Refused |
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1 O 13-19 2 O 20-29 |
3 O 30-39 4 O 40-49 |
5 O 50-59 6 O 60-69 |
7 O 70-79 8 O 80+ |
9 O DK 10 O Refused 11 O DA |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | charlene.doyle |
File Modified | 0000-00-00 |
File Created | 2021-02-01 |