NHTSA Form 1171 Intake Questionnaire for Instrumented On-Road Study of M

OMB Control No. 2127-xxxxx

Expiration Date xx/xx/xxxx

Intake Questions

Please note 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 be approximately 75 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.

Demographics

1. Gender

• Male

• Female

2. Year of Birth: __________

Riding History

3. How old were you when you obtained your motorcycle license / endorsement?

__________

4. How old were you when you began riding STREET/ON-ROAD motorcycles?

__________

5. How old were you when you began riding motorcycles OFF-ROAD?

__________

 I never road off-road.

6. How many different STREET motorcycles have you ridden regularly in the last 12 months?

__________

7. How many motorcycles do you currently own or lease?

__________

8. Since you began riding a street motorcycle, have you ever taken a break from riding that lasted for a year or more?

• Yes

• No (Skip to Question 12)

9. How many years did your most recent break from riding a street motorcycle last?

__________

10. How many years had you ridden a street motorcycle before taking your most recent break from riding?

__________

11. How old were you when you returned to riding a street motorcycle after taking that most recent break?

__________

The following section pertains to how you ride the motorcycle you will be using in this study. A trip is defined as the travel period from the place you started to your destination (which may be the same place you started). Stops along the way, like breaks or for fuel, are included in one trip.

12. What year did you purchase this motorcycle?

__________

13. Did you purchase this motorcycle new or used?

• New

• Used

14. How often do you ride this motorcycle?

Days: __________

per (week, month, year):__________

15. Approximately how many miles did you ride this motorcycle on the road in the last 12 months?

__________

16. Approximately how many miles did you drive a car in the last 12 months?

__________

17. Do you have a riding season?

• Yes

• No, I ride all year. (Please skip to Question 20.)

18. Approximately what month do you begin your riding season, if any?

• January

• February

• March

• April

• May

• June

• July

• August

• September

• October

• November

• December

19. Approximately what month do you end your riding season, if any?

• January

• February

• March

• April

• May

• June

• July

• August

• September

• October

• November

• December

20. Which of the following best describes your riding?

• I commute on a motorcycle at least once a week during my riding season; I do not ride specifically for pleasure.

• I commute on a motorcycle at least once a week during my riding season; I also ride for pleasure.

• I sometimes ride to commute, but not consistently. I also ride sometimes for pleasure.

• I ride mostly for pleasure; I rarely commute on a motorcycle.

21. During your last riding season (or last year if you ride all year), how many of your rides were for commuting to and from work, running errands, etc?

• All

• Most

• Some

• Few

• None

22. During your last riding season (or last year if you ride all year), how many of your rides were for pleasure only?

• All

• Most

• Some

• Few

• None

23. How did you learn to ride? (Select all that apply)

• Taught self

• Taught by family member/friend

• Training course

• Other: __________

24. Have you taken a motorcycle training course (e.g., Motorcycle Safety Foundation)?

• Yes

• No (Please skip to Question 27.)

25. What types of motorcycle training courses have you taken? (Select all that apply)

• Entry-level riding course

• Experienced riding course

• Other: __________

26. In what year did you take your most recent motorcycle training course? __________

27. What type of helmet do you wear most often while riding?

• Do not wear a helmet

• Full-face

• Three quarter shell

• Half shell

28. Do you wear a helmet when riding in states which do not require helmet use?

• Yes

• No

Perceptions

Directions: Please indicate the appropriate choice for each of the items below.

		Strongly disagree	Disagree	Neither disagree or agree	Agree	Strongly agree
1.	I would like to explore strange places					
2.	I get restless when I spend too much time at home					
3.	I like to do frightening things					
4.	I like wild parties					
5.	I would like to take off on a trip with no pre-planned routes or timetables					
6.	I prefer friends who are excitingly unpredictable					
7.	I would like to try bungee jumping					
8.	I would love to have a new and exciting experiences, even if they are illegal					
9.	I follow all the road rules when I ride with friends					
10.	Speeding at any time is dangerous					
11.	More bad than good comes from ignoring road rules					
12.	I now ride more safely and try not to break road rules because I have been caught by the police in the past					

Please answer the following questions on the basis of your usual or typical feelings about motorcycle riding, using the scale: 1 = Not at all to 7 = Very much.

13. I would like to risk my life as a motorcycle racer.	1	2	3	4	5	6	7
14. I sometimes like to frighten myself a little while riding.	1	2	3	4	5	6	7
15. I get a real thrill out of riding fast.	1	2	3	4	5	6	7
16. I like to raise my adrenaline levels while riding.	1	2	3	4	5	6	7
17. I would enjoy riding on a road with no speed limit.	1	2	3	4	5	6	7
18. I enjoy the sensation of accelerating rapidly.	1	2	3	4	5	6	7
19. I enjoy cornering at high speed.	1	2	3	4	5	6	7
20. In general I enjoy riding.	1	2	3	4	5	6	7

NEO-FFI

Please read each statement carefully and then circle the number that best represents your opinion of yourself according to the answer choices below.

Strongly

_Disagree

Disagree Neutral Agree Strongly

_Agree

1. I am not a worrier 1 2 3 4 5

2. I like to have a lot of people around me 1 2 3 4 5

3. I don’t like to waste my time daydreaming 1 2 3 4 5

4. I try to be courteous to everyone I meet 1 2 3 4 5

5. I keep my belongings clean and neat 1 2 3 4 5

6. I often feel inferior to others 1 2 3 4 5

_{7. I laugh easily 1 2 3 4 5}

8. Once I find the right way to do something, I stick to it

9. I often get into arguments with my family and co-workers

10. I’m pretty good about pacing myself so as to get things done on time

11. When I’m under a great deal of stress, sometimes I feel like I’m going to pieces

12. I don’t consider myself especially “light- hearted”

13. I am intrigued by the patterns I find in art and nature

14. Some people think I’m selfish and egotistical

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

15. I am not a very methodical person 1 2 3 4 5

16. I rarely feel lonely or blue 1 2 3 4 5

_{17. I really enjoy talking to people 1 2 3 4 5}

18. I believe letting students hear controversial speakers can only confuse and mislead them

1 2 3 4 5

19. I would rather cooperate with others than compete with them

20. I try to perform all the tasks assigned to me conscientiously

1 2 3 4 5

1 2 3 4 5

21. I often feel tense and jittery 1 2 3 4 5

22. I like to be where the action is 1 2 3 4 5

_{23. Poetry has little or no effect on me 1 2 3 4 5}

24. I tend to be cynical and skeptical of others’ intentions

25. I have a clear set of goals and work toward them in an orderly fashion

1 2 3 4 5

1 2 3 4 5

26. Sometimes I feel completely worthless 1 2 3 4 5

27. I usually prefer to do things alone 1 2 3 4 5

_{28. I often try new and foreign foods 1 2 3 4 5}

29. I believe that most people will take advantage of you if you let them

30. I waste a lot of time before settling down to work

1 2 3 4 5

1 2 3 4 5

_{31. I rarely feel fearful or anxious 1 2 3 4 5}

32. I often feel as if I’m bursting with energy

33. I seldom notice the moods or feelings that different environments produce

1 2 3 4 5

1 2 3 4 5

34. Most people I know like me 1 2 3 4 5

_{35. I work hard to accomplish my goals 1 2 3 4 5}

36. I often get angry at the way people treat me

1 2 3 4 5

_{37. I am a cheerful, high-spirited person 1 2 3 4 5}

38. I believe we should look to our religious authorities for decisions on moral issues

39. Some people think of me as cold and calculating

40. When I make a commitment, I can always be counted on to follow through

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

41. Too often, when things go wrong, I get discouraged and feel like giving up

1 2 3 4 5

_{42. I am not a cheerful optimist 1 2 3 4 5}

43. Sometimes when I am reading poetry or looking at a work of art, I feel a chill or wave of excitement

44. I am hard-headed and tough-minded in my abilities

45. Sometimes I’m not as dependable or reliable as I should be

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

46. I am seldom sad or depressed 1 2 3 4 5

_{47. My life is fast-paced 1 2 3 4 5}

48. I have little interest in speculating on the nature of the universe or the human condition

49. I generally try to be thoughtful and considerate

50. I am a productive person who always gets the job done

51. I often feel helpless and want someone else to solve my problems

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

52. I am a very active person 1 2 3 4 5

53. I have a lot of intellectual curiosity 1 2 3 4 5

54. If I don’t like people, I let them know it 1 2 3 4 5

_{55. I never seem to be able to get organized 1 2 3 4 5}

56. At times I have been so ashamed I just want to hide

57. I would rather go my own way than be a leader of others

58. I often enjoy playing with theories or abstract ideas

59. If necessary, I am willing to manipulate people to get what I want

60. I strive for excellence in everything I do

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

MRBQ

When riding, how often do each of the following things happen to you?

(Tick ONE box on EACH line.)

	Never	Hardly Ever	Occasionally	Quite Often	Frequently	All the Time
Fail to notice that pedestrians are crossing when turning into a side street from a main road	1	2	3	4	5	6
Not notice someone stepping out from behind a parked vehicle until it is nearly too late	1	2	3	4	5	6
Not notice a pedestrian waiting to cross at a crosswalk, or in a crosswalk	1	2	3	4	5	6
Pull out on to a main road in front of a vehicle that you had not noticed, or whose speed you have misjudged	1	2	3	4	5	6
Miss yield signs and narrowly avoid colliding with traffic having the right of way	1	2	3	4	5	6
Fail to notice or anticipate that another vehicle might pull out in front of you and have difficulty stopping	1	2	3	4	5	6
Waiting behind a vehicle to turn right on a main road, you pay such close attention to the main traffic that you nearly hit the vehicle in front	1	2	3	4	5	6
Distracted or pre-occupied, you belatedly realize that the vehicle in front has slowed and you have to brake hard to avoid a collision	1	2	3	4	5	6
Attempt to overtake someone that you had not noticed to be signaling a left turn	1	2	3	4	5	6
When riding at the same speed as other traffic, you find it difficult to stop in time when a traffic light has turned against you	1	2	3	4	5	6
Ride so close to the vehicle in front that it would be difficult to stop in an emergency	1	2	3	4	5	6
Run wide when going round a corner	1	2	3	4	5	6
Ride so fast into a corner that you feel like you might lose control	1	2	3	4	5	6
Exceed the speed limit on a country/rural road	1	2	3	4	5	6
Disregard the speed limit late at night or in the early hours of the morning	1	2	3	4	5	6
Exceed the speed limit on a highway	1	2	3	4	5	6
Exceed the speed limit on a residential road	1	2	3	4	5	6
Race away from traffic lights with the intention of beating the driver/rider next to you	1	2	3	4	5	6
Open up the throttle and just ‘go for it’ on country/rural roads	1	2	3	4	5	6
Ride between two lanes of fast moving traffic	1	2	3	4	5	6
Get involved in unofficial ‘races’ with other riders or drivers	1	2	3	4	5	6
Ride so fast into a corner that you scare yourself	1	2	3	4	5	6
Attempt to do, or actually do, a wheelie	1	2	3	4	5	6
Pull away too quickly and your front wheel comes off the road	1	2	3	4	5	6
Intentionally do a wheel spin	1	2	3	4	5	6
Unintentionally do a wheel spin	1	2	3	4	5	6
Wear riding boots?	1	2	3	4	5	6
Wear protective pants (leather or non-leather)?	1	2	3	4	5	6
Wear a protective jacket (leather or non-leather)?	1	2	3	4	5	6
Wear body armor (elbow pads, shoulder pads, knee pads, etc)	1	2	3	4	5	6
Wear no protective clothing?	1	2	3	4	5	6
Wear gloves?	1	2	3	4	5	6
Wear bright/fluorescent strips/patches on your clothing	1	2	3	4	5	6
Use low beam headlights on your bike?	1	2	3	4	5	6
Brake or reduce throttle when going round a corner or bend	1	2	3	4	5	6
Change gear when going round a corner or bend	1	2	3	4	5	6
Find that you have difficulty controlling the bike when riding at speed (e.g. steering wobble)	1	2	3	4	5	6
Skid on a wet road or manhole cover	1	2	3	4	5	6
Have trouble with your visor or goggles fogging up	1	2	3	4	5	6
Driver deliberately annoys you or puts you at risk	1	2	3	4	5	6
Ride when you suspect you might be over the legal limit for alcohol	1	2	3	4	5	6
Wear a leather one-piece suit?	1	2	3	4	5	6
Wear bright/fluorescent clothing?	1	2	3	4	5	6

12

NHTSA Form 1171