NHTSA
Form 1122 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 total 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.
Hello, I'm of [FILL IN COMPANY NAME]. We are surveying people on behalf of the U.S. Department of Transportation. You have not done anything wrong and this is not a sales survey. We are offering $10 to participate in a TWO-PART survey. We are conducting a study of the driving behaviors and alcohol use of residents of [JURISDICTION]. We would like to ask you some questions and take a sample of your breath to be analyzed later for alcohol. 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 and breath sample for the first part of the survey takes about 5 minutes to complete.
[Interviewer Note: If necessary, read]: 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 [END]
Consented to complete the survey [CONTINUE]
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
Other (Specify____________)
Don't know
Refused
Activate PAS for reading
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In the past year, how often did you have a drink containing alcohol?
Never [Skip to Question 10]
Less than monthly [Go to Question 4]
Monthly [Go to Question 4]
Weekly [Go to Question 4]
Daily/almost daily [Go to Question 4]
Don’t know [Go to Question 4]
Refused [Go to Question 4]
Assess estimated level of intoxication
No signs of alcohol or drug use [Level 1]
Signs of use but no intoxication [Level 2]
Signs of use and intoxication [Level 3] If level 3– Implement IDP
For Level 3 subjects: Continue asking questions while observing subject and determine: (1) if subject has the ability to give consent, and (2) if the interview should be stopped and the IDP activated.
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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
Didn’t drink alcohol in past 30 days [Skip to Question 8]
Refused
In the past 30 days, how often did you have 5 (4 for a woman) or more drinks in a two-hour period?
Never
Less than monthly
Monthly
Weekly
Daily/almost daily
Refused
Record PAS reading
00
1 green
2 green
1 yellow
2 yellow
3 yellow
4 yellow (Implement IDP)
1 red (Implement IDP)
2 red (Implement IDP)
3 red (Implement IDP)
Not used
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
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 11]
No [Skip to Question 12]
Don’t know [Skip to Question 12]
Refused [Skip to Question 12]
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 a 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 13]
No [Skip to Question 14]
Don’t Know [Skip to Question 14]
Refused [Skip to Question 14]
Where did you see or hear about the drunk driving enforcement? [DO NOT READ--MULTIPLE RESPONSES ACCEPTED]
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Was it a…
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Was it a…
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Was it a…
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Was it a…
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Now I need some information about you.
What is your age?
Age_________________
Refused
Do you consider yourself to be Hispanic or Latino?
Yes
No
Not sure
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 your Zip Code?
Zip Code____________________
Don’t know
Refused
BREATH SAMPLE:
“Now I’d like to get a
sample of your breath. Our device does not display any readings and
there is no risk to you.” [Show
PBT to subject]
“This will take just a few seconds.”
“I will indicate on my survey that you said”: YES NO
[Take breath sample with PBT]
RECORD PBT NUMBER __ __ __ __ RECORD PBT TEST NUMBER: __ __ __ _
That completes the first portion of the survey. On your way out of the bar tonight, please look for one of our surveyors in blue. [Place ID band on participant.] This bracelet has an ID code which will link your survey to the second survey in this study (completed upon exiting the establishment). This second survey and breath sample should take no longer than 3 minutes. We will give you your $10 incentive once this second portion has been completed.
Thanks for taking the time to participate in this research study.
RECORD: Group #: _____ Individual #: ______ Of # ______
NOTE: SELECT GENDER BY OBSERVATION - Male or Female?
Male
Female
NHTSA
Form
1122 OMB
#xxxx-xxxx
Expiration Date: Month xx, xxxx
Welcome back, I'm . As we told you earlier in the evening we are surveying people on behalf of the U.S. Department of Transportation. This is the second part of the survey where you may collect the $10 we offered as you first came in to complete the survey. Remember, 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 3 minutes to complete.
[Interviewer Note: If necessary, read]: 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.
RECORD: Group #: _____ Individual #: ______ Of #: ______
May I begin?
Refused to complete the survey [END]
Consented to complete the survey [CONTINUE]
Refused
Activate PAS for reading
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Assess estimated level of intoxication
No signs of alcohol or drug use [Level 1]
Signs of use but no intoxication [Level 2]
Signs of use and intoxication [Level 3] If level 3– Implement IDP
For Level 3 subjects: Continue asking questions while observing subject and determine: (1) if subject has the ability to give consent, and (2) if the interview should be stopped and the IDP activated.
Record PAS reading
00
1 green
2 green
1 yellow
2 yellow
3 yellow
4 yellow [Implement IDP]
1 red [Implement IDP]
2 red [Implement IDP]
3 red [Implement IDP]
Not used
How often do you drink in bars or restaurants?
Never
Less than monthly
Monthly
Weekly
Daily/almost daily
Refused
How many drinks did you have tonight? _______________
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
BREATH SAMPLE:
“Now I’d like to get a
sample of your breath. Our device does not display any readings and
there is no risk to you.” [Show
PBT to subject]
“This will take just a few seconds.”
“I will indicate on my survey that you said”: YES NO
[Take breath sample with PBT]
RECORD PBT NUMBER __ __ __ __ RECORD PBT TEST NUMBER: __ __ __ _
“It is important for you to know that our breathalyzer cannot provide information at this time about your drinking. You should not conclude from our brief interview that it is safe for you to drive if you have been drinking. Any amount of alcohol or drugs increases chances of being in a traffic crash and causing accidental injury or death to yourself and others. So does driving in a state of extreme exhaustion. If you are unable to drive home safely, we encourage you to use public transportation or we will provide you with FREE transportation home. Please do not hesitate to ask for assistance in getting home safely tonight."
That completes the survey. [Surveyor gives the $10 money order incentive.]
Thanks for taking the time to participate in this research study.
| File Type | application/msword |
| File Title | ATTACHMENT C |
| Author | MLevy |
| Last Modified By | alan.block |
| File Modified | 2012-05-15 |
| File Created | 2012-02-01 |