OMB #xxxx-xxxx
Expiration Date: Month xx, xxxx
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-xxxx. Public reporting for this collection of information is estimated to be approximately (10) 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, (NHTSA, 1200 New Jersey Ave, SE, Washington, D.C. 20590.
Introduction:
Hello, I'm [FILL IN APPROPRIATE NAME] of [FILL IN COMPANY NAME]. I am calling on behalf of the U.S. Department of Transportation.
Are you currently driving or doing anything else that would make it unsafe for you to be on the phone?
Yes - [Terminate and Set Unscheduled Callback]
No - [Go to Continuation of Introduction]
DON’T KNOW [Thank and end call]
REFUSED [Thank and end call]
Introduction (Continued):
We are conducting a study of the driving behaviors and alcohol use of residents of [JURISDICTION], and would like to ask you a few questions on an anonymous basis. We are not selling anything. This survey is voluntary and will only take about 10 minutes.
Have I reached you on a cell phone?
Yes [Go to Question 3]
No [Go to Question 5]
DON’T KNOW [Thank and end call]
REFUSED [Thank and end call]
Are you 18 years or older and a motor vehicle driver?
Yes [Go to Question 4]
No [Thank and end call]
DON’T KNOW [Thank and end call]
REFUSED [Thank and end call]
NHTSA Form 1121
In the past year, how often did you have a drink containing alcohol?
Never [Thank and end call]
Less than monthly [Go to Consent]
Monthly [Go to Consent]
Weekly [Go to Consent]
Daily/almost daily [Go to Consent]
Don’t know [Thank and end call]
Refused [Thank and end call]
Is there a person living in this household who is 18 years or older and is a motor vehicle driver?
Yes - [Go to Question 6]
No [Thank and end call]
DON’T KNOW [Thank and end call]
REFUSED [Thank and end call]
May I please speak with the person in the household who will have the next birthday and who is at least 18 years old and is a motor vehicle driver?
Yes – Speaking with eligible person [Go to Question 7]
Yes – Person on Phone Retrieves Eligible Person [Once eligible person on phone, repeat introduction and go to Question 7]
No – Person not available [Set call back time]
No [Thank and end call]
DON’T KNOW [Thank and end call]
REFUSED [Thank and end call]
In the past year, how often did you have a drink containing alcohol?
Never [Thank and end call]
Less than monthly [Go to Consent]
Monthly [Go to Consent]
Weekly [Go to Consent]
Daily/almost daily [Go to Consent]
Don’t know [Thank and end call]
Refused [Thank and end call]
The interview is voluntary, even if you agree to take part in the survey you may stop participating at any time. The information you provide us will be used for research purposes only. We will not collect any personal information that would allow anyone to identify you. The interview takes about 10 minutes to complete.
[Interviewer Note: If necessary, read]: Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. The Office of Management and Budget (OMB) control number for this study is xxxx-xxxx.
May I begin?
Refused to complete the survey [Thank and end call]
Consented to complete the survey [Continue to Question 8]
What is your age?
Age___________
Refused
[If refused, ask, “If you prefer not to give me your exact age, could you please identify your age category?”]
<18 [Thank and end call]
18 to 20 [Continue to Question 9]
21 to 24 [Continue to Question 9]
25 to 34 [Continue to Question 9]
35 to 39 [Continue to Question 9]
40 to 49 [Continue to Question 9]
50 to 54 [Continue to Question 9]
55 to 64 [Continue to Question 9]
65 or older [Continue to Question 9]
INTERVIEWER: RECORD GENDER OF RESPONDENT BY OBSERVATION
Male
Female
How often do you drive a motor vehicle? Almost every day, a few days a week, a few days a month, or a few days a year?
Almost every day
Few days a week
Few days a month
Few days a year
Never [Thank and end call]
Other (SPECIFY__________________)
Don't know
Refused
How much of your driving is done after dark? [READ LIST]
None
Very little
Less than half
About half
More than half
All
Don’t know
Refused
Is the vehicle you drive most often a car, van, motorcycle, pickup truck, sport utility vehicle, or other type of truck? [NOTE: IF RESPONDENT DRIVES MORE THAN ONE VEHICLE OFTEN, ASK:] "What kind of vehicle did you LAST drive?"
Car
Van or minivan
Motorcycle
Pickup truck
Sport Utility Vehicle
Other truck (SPECIFY________________)
Other (SPECIFY_________________)
Don't know
Refused
Which of the following statements best describes your driving?
I tend to pass other cars more often than other cars pass me, or
Other cars tend to pass me more often
(Volunteered) Passing rate is about even
Don’t know
Refused
How many times in the last year have you been stopped for a traffic violation?
Number of stops__________________
Don’t know
Refused
In the past 30 days, how many drinks containing alcohol did you have on a typical day when you were drinking?
1-2
3-4
5-6
7-9
10 or more
Don’t know
Refused
In the past 30 days, how often did you have 5 (4 for a woman) or more drinks of alcohol in a two-hour period?
Never
Less than monthly
Monthly
Weekly
Daily/almost daily
Refused
Where do you most often drink alcoholic beverages?
Bar
Restaurant
Friend’s house or party
Home
Sports stadium/sporting event
Picnic/camping/outdoor event
In car
Do not drink alcohol
Don’t know
Other
Refused
How many days out of the past 30 days did you drive within two hours after drinking any alcoholic beverages?
ENTER NUMBER OF DAYS__________ (Range=0-30)
Don’t know
Refused
If 0, Go to Question 20.
On the most recent occasion when you drove within two hours after drinking alcoholic beverages, how many drinks (of beer, wine, liquor) did you have?
ENTER NUMBER of DRINKS _____(Range=01-90)
Don't know
Refused
In the past 30 days, have you ever deliberately avoided driving a motor vehicle because you felt you probably had too much to drink to drive safely?
Yes
No
Don’t know
Refused
Have you ever felt the need to cut down on your drinking?
Yes
No
Don’t know
Refused
Have people annoyed you by criticizing your drinking?
Yes
No
Don’t know
Refused
Have you ever felt badly or guilty about your drinking?
Yes
No
Don’t know
Refused
Have you ever had a drink first thing in the morning (eye-opener)?
Yes
No
Don’t know
Refused
In the past 30 days, have you seen police on the roads you normally
drive:
[READ LIST]
More often than usual
Less often than usual
About the same
Never
Don't know
Refused
Suppose you drove a motor vehicle after drinking alcohol and the amount of alcohol in your body was more than what the law allows for drivers. How likely is it that the police would stop you? Would the police be...........?
Very likely to stop you
Somewhat likely to stop you
Not likely to stop you
Don’t know
Refused
How likely is it that [Perceived Enforcement Risk in Community]?
Very likely
Somewhat likely
Not very likely
Don’t know
Refused
How likely is it that [Perceived Enforcement Risk in Community]?
Very likely
Somewhat likely
Not very likely
Don’t know
Refused
How likely is it that [Perceived Safety Risk in Community]?
Yes
No
Don’t know
Refused
How likely is it that [Perceived Safety Risk in Community]?
Very likely
Somewhat likely
Not very likely
Don’t know
Refused
Yes or No--in the past 30 days, have you seen or heard of any effort by police in your community to reduce driving under the influence or drunk driving?
Yes [Go to Question 32]
No [Skip to Question 34]
Don’t know [Skip to Question 34]
Refused [Skip to Question 34]
Is the effort by police to reduce driving under the influence or drunk driving, occurring only during daytime hours, nighttime hours, or both daytime and nighttime hours?
Daytime hours
Nighttime hours
Both
Don’t know
Refused
In your opinion, how often is this police effort happening?
[READ
LIST – ONE REPONSE]
Regularly (happening on a continuing basis – daily, weekly, etc.)
Occasionally (happening few times a year)
One-time only
Don’t know
Refused
In the past 30 days, have you seen or heard any messages that mention drunk driving enforcement? This could be public service announcements on TV, messages on the radio or your phone, signs on the road, news stories, communication via the internet including computer games, or something else?
Yes [Go to Question 35]
No [Skip to Question 36]
Don’t know [Skip to Question 36]
Refused [Skip to Question 36]
I
Where did you see or hear about the drunk driving enforcement? [DO NOT READ LIST OF INITIAL RESPONSES--MULTIPLE RESPONSES ACCEPTED]
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In the past 30 days, have you seen or heard anything about police setting up checkpoints to catch drivers who were driving while under the influence of alcohol or driving drunk?
Yes [Go to Question 37]
No [Skip to Question 38]
Don’t know [Skip to Question 38]
Refused [Skip to Question 38]
In the past 30 days, did you personally drive past, or drive through, a police checkpoint set up to catch drivers who were driving while under the influence of alcohol or driving drunk?
Yes
No
Don’t know
Refused
In the past 30 days, have you seen or heard [Specific Community Program Activity]?
Yes
No
Don’t know
Refused
In the past 30 days, have you seen or heard [Specific Community Program Activity]?
Yes
No
Don’t know
Refused
DEMOGRAPHICS
Now I need some information about you.
Do you consider yourself to be Hispanic or Latino?
Yes [Go to Question 41]
No [Skip to Question 42]
Not sure [Go to Question 42]
Do you speak Spanish at home?
Yes
No
Refused
Which of the following racial categories describes you? You may select more than one. [READ LIST--MULTIPLE RECORD]
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
[DO NOT READ] Other (Specify_______________)
Refused
What is the highest grade or year of school you completed? [DO NOT READ LIST]
8th grade or less
9th grade
10th grade
11th grade
12th grade/GED
Some college
College graduate or higher
Refused
Are you currently a student?
High School
College
No
Other
Refused
Please stop me when I reach the category that includes your household’s total annual income for last year, that is, 2011: [READ LIST UNTIL RESPONDENT STOPS YOU TO SELECT A CATEGORY]
Under $15,000
From $15,000 to less than $30,000
From $30,000 to less than $50,000
From $50,000 to less than $75,000
From $75,000 to less than $100,000
From $100,000 to less than $125,000
$125,000 or more
Don’t know
Refused
What is your Zip Code?
Zip Code____________________
Don’t know
Refused
That concludes our interview. We greatly appreciate your time and opinions.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | ATTACHMENT C |
| Author | MLevy |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |