Form NHTSA Form 1164 NHTSA Form 1164 CIOT Screener

OMB Control No. 2127-0682

Expiration Date 02/28/2015

RECRUITMENT SCREENER FOR FOCUS GROUPS

TO ASSESS ADVERTISING CONCEPTS SUPPORTING

CLICK IT OR TICKET, 2012 CAMPAIGN

OMB# 2127-0682

NOTE TO RECRUITER: Ask to speak to any male age 18 to 34 (note: sex and age range are critical). If none available, terminate.

Hello, I'm __________________ calling for the (NAME OF FOCUS GROUP COMPANY). We are conducting a brief survey among people in our area about driving.

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 2127-0682. 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, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590

Could we begin now?

1. Do you, or does anyone in your immediate family, work in any of the following industries or professions? (NOTE TO RECRUITER: Read list. Terminate if “yes”to any)

__ Marketing, advertising, public relations or marketing research

__ Graphic design

__ News media, including newspaper, television, radio or publishing

__ Law enforcement

__ Legal

__ Local, state or federal government

2. Are you a licensed driver?

____ Yes ____ No (terminate)

3. In which of these age groups is your age? (NOTE TO RECRUITER: Read list of the two age groups)

____ 18-25

____ 26-34

____ “Neither,” other or refused (terminate)

NOTE TO RECRUITER IN EACH CITY WHERE

FOCUS GROUPS ARE HOSTED:

Recruit for a total of four groups. Two groups will be composed of men ages 18-25; two other groups will be men ages 26-34.

4. During a typical week, about how many days do you drive at least 10 miles per day? (NOTE TO RECRUITER: read list):

____ About once a week or less (terminate)

____ 2 or more times per week

5. Which of the following types of vehicles do you drive most often for personal, non-business travel? (NOTE TO RECRUITER: read list; accept only the one driven most often):

____ Automobile

____ Mini-van

____ Full-size van

____ Sport utility vehicle

____ Pick-up truck

____ None of these (terminate)

(NOTE TO RECRUITER: “none of these” includes motorcycles)

NOTE TO RECRUITER: The next question is an articulation question. What the respondent says is not important; rather, judge his ability and willingness to comment with a specific point-of-view.

6. In your opinion, what would be the best way to minimize traffic congestion on highways in the (city) area?

____ Articulate

____ Not articulate (terminate)

7. The next question is about seatbelts. Tell me if in any of the situations I’ll describe, you sometimes don’t wear a seatbelt while driving (NOTE TO RECRUITER: read list. A “yes” answer to any one or more qualifies the respondent. If “no” to all, terminate):

____ Just a short trip to a store or nearby place

____ When wearing nice clothes that might get wrinkled by a seatbelt

____ When on a road with little or no traffic

____ Sometimes when you just forget to buckle up

____ When driving on roads at low speeds

8. Are you of Hispanic or Latino origin?

____ Hispanic or Latino (quota per group: need at least 2, but no more

than 3)

____ Not Hispanic or Latino

____ Refused (terminate)

9. What is your race?  Please select one or more. ---- (NOTE TO RECRUITER: read list and check all that apply; OK to repeat list if asked)

____ American Indian or Alaska Native

____ Asian

____ Black or African American (quota per group: need at least 2, but no more

than 3)

____ Native Hawaiian or Other Pacific Islander

____ White

____ Refused (terminate)

Based on your responses, we would like to invite you to participate in a focus group research study about advertising campaign ideas. The group discussion will be about an hour-and-fifteen-minutes in length, and for your participation, you will receive $75 cash. As many as eight others will participate. The meeting will be on (SCHEDULED DATE) at (SCHEDULED START TIME) p.m. It will be at our focus group research facility at (FOCUS GROUP FACILITY ADDRESS/LOCATIONAL INFORMATION).

(NOTE TO RECRUITER: Convey additional appropriate details if respondent is willing to participate)

NHTSA Form 1164 Page 6