Form NHTSA Form 1272 NHTSA Form 1272 Survey for Seat Belt Safety Public Service Advertising C

OMB No. 2127-0682
Expiration Date: xx/xx/xxxx

Survey for Seat Belt Safety Public Service Advertising Campaign

[INTRODUCTION] Thank you for agreeing to participate in this online study. The survey will take about 10-15 minutes to complete. All responses are anonymous and will only be viewed in aggregate.

This study is being conducted on behalf of the National Highway Traffic Safety Administration (NHTSA). 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 OMB control number for this study is 2127-0682. This survey is voluntary. We will not collect any personal information that would allow anyone to identify you. Any information you do provide will be kept private to the fullest extent of the law. 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., W51-316, Washington, DC, 20590

1. We are looking for people who work in certain occupations and industries. Do you or does anyone in your household work in any of the following occupations or industries? (Please select all that apply).

1. Market Research

2. Advertising Agency / Public Relations

3. Marketing

4. Automobile manufacturing or sales

5. Manufacturer, Distributor or Seller of household paper products

6. A company that supplies or sells telephone, cellular or Internet services

7. Insurance

8. Banking

9. None of these

IF “MARKET RESEARCH” OR “ADVERTISING AGENCY / PUBLIC RELATIONS” OR “MARKETING” OR “Automobile manufacturing or sales” THEN TERMINATE, OTHERWISE CONTINUE

2. Are you the parent or guardian of any children under the age of 18 who are living in your household?

1. Yes [GO TO Q2a.]

2. No [SKIP TO Q3]

2a. How old are your children? (Select all that apply)
MULTIPLE RESPONSE

1. Under 8 years [TERMINATE]

2. 8-11 years [CONTINUE TO Q4]

3. 12-14 years [CONTINUE TO Q4]

4. 15 years or older [TERMINATE]

IF CHILD AGE “8-11 YEARS” OR “12-14 YEARS” CHECKED, THEN CONTINUE; IF “UNDER 8 YEARS” AND/OR “15 YEARS OR OLDER” ARE THE ONLY SELECTIONS CHECKED, TERMINATE.

3. Do you look after children for family or friends for three or more days per week regularly?

1. Yes [CONTINUE TO Q3a]

2. No [TERMINATE]

3a. How old are the children you care for? (Select all that apply)
MULTIPLE RESPONSE

1. Under 8 years [TERMINATE]

2. 8-11 years

3. 12-14 years

4. 15 years or older [TERMINATE]

IF CHILD AGE “8-11 YEARS” OR “12-14 YEARS” CHECKED, THEN CONTINUE; IF “UNDER 8 YEARS” AND/OR “15 YEARS OR OLDER” ARE THE ONLY SELECTIONS CHECKED, TERMINATE.

4. What is your gender?

1. Male

2. Female

RECRUIT 50% FEMALE, 50% MALE

5. What is your age? _________ PROGRAMMER NOTE: MUST BE 25+

1. 18-24 years [TERMINATE]

2. 25-34 years

3. 35-44 years

4. 45-54 years

5. 55+ years

6. Refused [TERMINATE]

6. Are you of Hispanic or Latino origin?

1. Yes

2. No

[If “Yes” in Q6:]

6a. In what country were you born?

1. Argentina

2. Bolivia

3. Chile

4. Columbia

5. Costa Rica

6. Cuba

7. Ecuador

8. El Salvador

9. Guatemala

10. Honduras

11. Mexico

12. Nicaragua

13. Panama

14. Paraguay

15. Peru

16. Puerto Rico

17. Dominican Republic

18. Uruguay

19. Venezuela

20. United States

21. Other/Refusal

6b. How many years have you lived in the United States?

1. Less than 1 year

2. 1-4 years

3. 5-10 years

4. 11-15 years

5. 16-20 years

6. More than 20 years

7. What is your race? Please select one or more. [Add popup option: “Why do we ask this question?”^*]

1. White

2. Black or African-American

3. Asian

4. Native Hawaiian or other Pacific Islander

5. American Indian or Alaska Native

8. What is the highest level of education that you have completed?

1. 8^th grade or below

2. 9th grade to 11th grade

3. High school graduate

4. Some college

5. Associate's degree

6. Bachelor's degree

7. Some postgraduate study

8. Graduate school degree

9. Trade school

10. None of the above/ Prefer not to state

9. Which classification best describes your total pre-tax household income? [*Add popup option: “Why do we ask this question?”]

1. Under $10,000

2. $10,000-$19,999

3. $20,000-$29,999

4. $30,000-$39,999

5. $40,000-$49,999

6. $50,000-$74,999

7. $75,000-$99,999

8. $100,000-$124,999

9. $125,000-$149,999

10. $150,000-$174,999

11. $175,000-$199,999

12. More than $200,000

13. Prefer not to state

10. Do you drive a car, truck, SUV, or van on a regular basis?

1. Yes

2. No [TERMINATE]

PROGRAMMER NOTE: INSTRUCTION 1

[If “Yes” in S2 and ONLY ONE AGE SELECTED in S3:]

“Please answer the rest of this survey with your child age [X] in mind.”

[“X” is the age RANGE of child 8-14 indicated in S3]

[If “Yes” in S2 and MULTIPLE AGES SELECTED in S3:]

“Please answer the rest of this survey with your child age [X] in mind.”

[“X” is the age RANGE of one child 8-14 indicated in S3, randomly selected from all AGES 8-14 indicated in S3]

11. How often do you drive with [your child(ren)/the child(ren) you care for], age [INSERT AGE OF CHILD] in the car?

1. Three days a week or more

2. Less than three days a week [TERMINATE]

3. I do not drive [TERMINATE]

IF “LESS THAN THREE DAYS A WEEK” OR “DO NOT DRIVE” THEN TERMINATE, OTHERWISE CONTINUE

11. Thinking about the car that you drive when you are with [your child(ren)/the child(ren) you care for], how often do you do each of the following?

	Always	Most of the time	Sometimes	Never
Lock your doors when you leave the car
Wear your seat belt
Ask others riding in the car to buckle their seat belt
Take the car in for tune-ups
Use a safety restraint like a car seat or a seat belt [for your child(ren)/the child(ren) you care for]
Recheck throughout the car ride whether your child(ren) is still wearing their seat belt

13. When you are driving in the car with [your child(ren)/the child(ren) you care for], age [INSERT AGE OF CHILD], how would you describe his or her seat belt usage?

My child wears his or her seat belt:

1. Every time, even on shorter car rides

2. Nearly every time

3. Most of the time

4. Some of the time

5. Rarely or never

6. Not sure

13. To the best of your knowledge, how would you describe [your child(ren)’s/the child(ren)’s you care for], seat belt usage when you are not driving in the car with him or her?

My child wears his or her seat belt:

1. Every time, even on shorter car rides

2. Nearly every time

3. Most of the time

4. Some of the time

5. Rarely or never

6. Not sure

15. Which of the following types of car safety restraints do you use for [your child/the child you care for], age [INSERT AGE OF CHILD] when they ride in the car with you when you’re driving. (Please select all that apply)

1. Booster seat

2. Adult seat belt

3. Another type of car safety restraint (Please specify)___

4. None of the above [MAKE EXCLUSIVE IF SELECTED]

5. Not sure [MAKE EXCLUSIVE IF SELECTED]

16. Have you recently seen, heard, or read messages about seat belt safety for [your child(ren)/the child(ren) you care for], age 8-14 in advertising, publicity, the media, the Web or other places?

1. Yes

2. No

3. Not sure

[IF YES TO Q16]

16b. Where was that…? (Accept multiple responses.)

[PROGRAMMER: SET UP AS A GRID BUT IF THE USER SELECTS NO FOR “SOME OTHER PLACE” THEY SHOULDN’T HAVE TO PROVIDE AN OPEN END ANSWER]

TV program	Yes	No
TV ad	Yes	No
Radio program	Yes	No
Radio commercial	Yes	No
Magazine article	Yes	No
Magazine ad	Yes	No
Newspaper article	Yes	No
Newspaper ad	Yes	No
Website content	Yes	No
Web ad	Yes	No
Outdoor billboards or outdoor posters	Yes	No
From friends or family	Yes	No
Car seat or vehicle owner’s manual	Yes	No
Hospital or physician’s office	Yes	No
Car seat fitting station	Yes	No
Automobile dealer	Yes	No
Some other place (Specify)__________	Yes	No

16. In the past year, have you sought information about seat belt safety specifically for [your child(ren)/the child(ren) you care for], age 8-14?

1. Yes

2. No

3. Not sure

17a. [IF YES] Where did you seek information about seat belt safety for [your child(ren)/the child(ren) you care for], age 8-14?

Please list all sources of information below. [OPEN-ENDED]

____________________________________________________________________________________

16. Have you ever heard of a website called SaferCar.gov/[insert specific sublink]?

1. Yes

2. No

3. Not sure

[RANDOMIZE ORDER OF AD RECOGNITION QUESTIONS: KEEP TV AND RADIO ADS TOGETHER IN BLOCKS & RANDOMIZE ADS WITHIN BLOCKS]

Below is a video of a public service ad you might see on TV or some other place. After you view the ad, please indicate if you have seen it before.

[INSERT VIDEO_1]

16. Have you seen this ad?

1. Yes

2. No

3. Not sure

[INSERT VIDEO_2]

16. Have you seen this ad?

1. Yes

2. No

3. Not sure

Below is an audio file of a public service ad you might hear on the radio. After you listen to the ad, please indicate if you have heard it before.

[INSERT AUDIO FILE_1]

16. Have you seen this ad?

1. Yes

2. No

3. Not sure

[INSERT AUDIO FILE_2]

16. Have you seen this ad?

1. Yes

2. No

3. Not sure

16. Have you seen any of these ads in a newspaper or magazine?

[INSERT PRINT AD MONTAGE]

1. Yes

2. No

3. Not sure

16. Have you seen any of these ads online?

[INSERT BANNER AD MONTAGE]

1. Yes

2. No

3. Not sure

16. Have you seen any of these ads someplace, such as on a poster, billboard, or bus shelter?

[INSERT OUTDOOR AD MONTAGE]

1. Yes

2. No

3. Not sure

The following background questions will help us divide the interviews into groups.

16. What is your marital status?

1. Single (never married)

2. Living together but not married

3. Married

4. Separated

5. Divorced

6. Widowed

7. Prefer not to state

16. Do you live in the city, suburbs, or some other area?

1. City

2. Suburbs

3. Small town

4. Rural community

5. Some other area

16. What state do you live in?

[DROP-DOWN BOX]

CODE FOR REGION

* These questions about [race/income] are important so that we make sure the voices of people in all different populations are represented. In this way, we can be fair and objective by adjusting our results based on the proportions of the various groups in the larger population.

Collecting data from all respondents on this question is important so that we can better and more reliably report differences and similarities between people of different backgrounds.

We understand that you might be concerned about sharing this information. Please be assured that the responses you provide are kept completely confidential. Any identifying information will be separated from your answers. Results are reported using the average, or pooled answers to the questions, instead of the responses of any one individual.

NHTSA Form 1272 Page 5