Form NHTSA Form 1261 NHTSA Form 1261 ODI Focus Group Screener - Attachment A

OMB Control No. 2127-0682

Expiration Date 02-28-2015

NHTSA: ODI Focus Groups Participant Screener

This collection of information is voluntary and will be used for formative purposes only so that we may develop and evaluate programs designed to reduce the number of traffic-related injuries and deaths. We will not collect any personal information that would allow anyone to identify you. 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 15 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, W51-316, 1200 New Jersey Ave, S.E., Washington, DC, 20590

NHTSA: ODI Focus Groups

Participant Screener

This screener is designed to ensure the respondents recruited into these focus groups include a mix of consumers based on age, gender, education, vehicle ownership and other demographic characteristics. The criteria will also ensure we are including consumers who have encountered potential vehicle defects so that campaign ideas are being tested with ODI’s key target audience.

1. In which of the following categories is your age?

   1. Under 18 [TERMINATE]

   2. 18 to 24

   3. 25 to 34

   4. 35 to 44

   5. 45 to 54

   6. 55 to 64

   7. 65 or older

2. Are you…?

   1. Male

   2. Female

3. Do you currently own or lease a passenger vehicle (i.e., car, SUV, truck, etc.)? [ACCEPT MULTIPLE RESPONSE]

   1. Yes – OWN

   2. Yes – LEASE

   3. No

[CONTINUE IF Q3=01; IF NOT A VEHICLE OWNER, TERMINATE]

4. How many vehicles do you currently own?

[ENTER WHOLE NUMBER]

5. Please select the make, model and year of these vehicles

   1. Year: [NUMERIC FIELD; 1949-2014]

   2. Make: [OPEN END]

   3. Model: [OPEN END]

6. Thinking about decisions relating to maintaining your current vehicle, would you say you have primary responsibility, have shared responsibility, or is someone else responsible for decision making on maintaining the vehicle over its lifecycle?

   1. I am the primary decision maker

   2. I share decision making with someone else

   3. Someone else makes the decisions [TERMINATE]

7. Thinking about the vehicle(s) you currently own or have owned in the past, have you ever experienced a safety defect in your vehicle, vehicle’s equipment or car seats and booster seats? This may include problems with the powertrain, interior electronics and hardware, airbags, seat belts and other issues.

   1. Yes

   2. No [SKIP TO Q9]

   3. Don’t know [SKIP TO Q9]

[ASK IF Q7=01]

8. What was this defect you experienced? Please be as specific as possible.

[OPEN END]

9. And do you currently own or have you ever owned a vehicle that has been part of a safety recall?

   1. Yes

   2. No

   3. Don’t know

[TERMINATE IF Q7=02-03 AND Q9=02-03; CONTINUE IF Q7=01 OR Q9=01]

10. Have you ever reported a potential vehicle defect, tire defect or child safety seat defect to a vehicle manufacturer or another organization, not your dealer or a mechanic?

    1. Yes

    2. No [QUALIFY AS POTENTIAL COMPLAINANT]

[ASK IF Q10=01]

11. To whom did you report this defect?

[OPEN END]

[“DOT”, “NHTSA”, “GOVERNMENT” - QUALIFY AS COMPLAINANT]

These last few questions are for classification purposes only.

12. How many children under the age of 18, if any, do you currently have living in your household?

1. None

2. 1

3. 2

4. 3

5. 4

6. 5 or more

[ASK IF Q12=02-06]

13. And in which of the following age groups are the children in your household? [ACCEPT MULTIPLE RESPONSE]

    1. Less than 2 years old

    2. 2 to 4 years old

    3. 5 to 7 years old

    4. 8 to 12 years old

    5. 13 to 17 years old

14. What is the last grade you completed in school?

1. Some grade school (1-8)

2. Some high school (9-11)

3. High school graduate (12)

4. Technical or vocational school

5. Some College

6. College Graduate

7. Graduate or Professional School

8. Other

15. Are you of Hispanic or Latino descent?

1. Yes

2. No

16. Select one or more of following that best describes your race? [ACCEPT MULTIPLE RESPONSES]

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

17. What is your current employment status?

1. Employed full-time

2. Employed part-time

3. Not employed

4. Retired

5. Student

6. Homemaker / Caregiver / Stay-at-home parent

7. Other

18. Which ONE of the following best describes your total household income?

1. Under $25,000

2. $25,000 to less than $50,000

3. $50,000 to less than $75,000

4. $75,000 to less than $100,000

5. $100,000 to less than $150,000

6. $150,000 to less than $200,000

7. $200,000 or more

Invitation to the Focus Groups

Based on your responses, we would like to invite you to participate in our Vehicle Safety focus group that is taking place on [DATE] at [TIME]. The focus group discussion will last for approximately 2 hours. Are you interested in participating?

1. Yes [SCHEDULE RESPONDENT]

2. No [THANK AND TERMINATE]

NHTSA: ODI Focus Groups
Attachment A - Participant Screener

NHTSA Form 1261

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