Form NHTSA Form 1187 NHTSA Form 1187 Screener Guide for Community Participants Focus Group Re

OMB Control No.: 2127-0682

Expiration Date: 01/31/2015

Recruitment Screening for Community Focus Groups to Develop Materials to Increase Seat Belt Use among Recently Arrived Hispanic Immigrants

NOTES TO RECRUITER: Ask to speak to any male or female, ages 18-40. You will need two groups:

• Group 1: Women and Men, ages 18-40

• Group 2: Male ages 18 -34

For each group, recruit 12 participants anticipating that 9 will attend. Attempt to recruit:

• Recently Arrived (Hispanic/Latino) in the United States (5 years or less)

• Acculturated Participants (more than 5 years in U.S.)

Hello, I’m from the National Latino Children’s Institute or local partner organization. I would like to invite you to participate in a brief survey about driving.

This collection of information is VOLUNTARY and will be used to recruit individuals to participate in a focus group meeting. Public reporting burden for this survey is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. We will not collect any personal information that would allow anyone to identify you. Please note that 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 currently valid OMB control number. The OMB control number for this collection is 2127-0682. 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.

1. Can we begin now?

Yes	Continue
No	Terminate
Unsure/Refused	Terminate

2. 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

__ Traffic Safety

3. Do you frequently drive or ride in a personal motor vehicle such as a passenger car, van, SUV or pick-up truck?

Yes	Continue
No	Terminate
Unsure/Refused	Terminate

4. Do you always wear your seatbelt when you drive/ride in a passenger car, van, SUV or pick-up truck?

Yes	Terminate
No	Continue
Unsure/Refused	Terminate

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

____ 18-34

____ 35-40

____ “Neither,” other or refused (terminate)

6. How long have you been in the United States:

Five years or less	Continue
More than five years	Continue
Unsure/Refused	Terminate

7. Would you be interested in participating in a focus group or discussion group on driver safety issues?

Yes	Continue
No	Close
Unsure/Refused	Close

Termination Script

Thank you for taking the time to answer our questions.

If they don’t qualify add: Unfortunately, we’re looking for individuals with different experiences than you.

If they qualify, read:

We are recruiting individuals to participate in a group discussion to help develop strategies and materials to increase seat belt use among recent Hispanic immigrants. This collection of information is VOLUNTARY and will be used for formative purposes only so that we may develop materials to increase seat belt use among recent Hispanic immigrants. We will not collect any personal information that would allow anyone to identify you.

I would like to invite you to be a part of this focus group. The focus group will take place on

Date: __________________________________ Time:_____________

Location: ______________________________________

For more information you can contact me by phone XXX-XXX-XXXX or via email. I look forward to speaking with you at the focus group.

NHTSA Form: 1187 3 | Page