NHTSA Form 1215 Instructional Staff Survey

Appendix C-4: Instructional Staff Survey

Expiration Date xx/xx/xxxx

OMB Control No. 2127-xxxx

Paperwork Reduction Act Burden Statement

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 5 minutes per respondent, 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 SE, Washington, DC 20590.

Wilson County is participating in an important research study. Your answers to the following questions are anonymous. Your participation will help your school receive special recognition. 

What is your gender?  Male  Female

What is your age?  Under 21  21-34  35-49  50-59  60 plus

What is your race?  White  Black/African American  American Indian or Alaska Native  Asian

 Hawaiian Native or Pacific Islander  _______________

Are you of Hispanic or Latino origin?  Yes  No

What is your role at school?

 Classroom Teacher  Specialty Class Teacher  Substitute Teacher  Teacher Assistant/Aid

 Administrator  Other __________

What grade(s) do you currently teach or work with? (Check all that apply)

 Kindergarten  1st  2nd  3rd  4th  5th  None

How important is it for elementary schools to teach the following topics:

Fire safety  Not important  Slightly important  Moderately important  Very important

Health  Not important  Slightly important  Moderately important  Very important

Bicycle safety  Not important  Slightly important  Moderately important  Very important

Pedestrian safety  Not important  Slightly important  Moderately important  Very important

Physical education  Not important  Slightly important  Moderately important  Very important

Personal security  Not important  Slightly important  Moderately important  Very important

Which of the following topics have you ever taught at the elementary school level (check all that apply)?

Fire safety  Teach now  Have taught before  Never taught

Health  Teach now  Have taught before  Never taught

Bicycle safety  Teach now  Have taught before  Never taught

Pedestrian safety  Teach now  Have taught before  Never taught

Physical education  Teach now  Have taught before  Never taught

Personal security  Teach now  Have taught before  Never taught

Are children at your school taught how to walk safely near traffic?

 Yes  No  Not sure/Don’t know

If yes, which of the following programs have been implemented during this school year?

 Walk to School Day

 Willy Whistle

NHTSA Form 1215

 Let’s Go NC

 Officer Friendly

 Other__________________

Please provide your opinions about the children you work with:

How well do they know the rules for walking safely near traffic?

 Not well  Slightly well  Moderately well  Very well

How safely do they behave when walking near traffic?

 Very unsafely  Somewhat unsafely  Somewhat safely  Very safely

How capable are they of walking safely near traffic without adult assistance?

 Not at all capable  Not very capable  Somewhat capable  Very capable

Over the course of this school year, did you learn anything new about walking safely near traffic?

 Yes  No  Not sure/Don’t know

If yes, what have you learned?_____________________________________________________________________

How can pedestrian safety be improved around your school? (Check all that apply)

 More sidewalks  More/better crosswalks  Police enforcement  More education for children

 Slower speeds  More crossing guards  More education for parents

 Other _________________________

Who should teach pedestrian safety to children in an elementary school?

 Classroom Teacher  Specialty Class Teacher (e.g., physical education)  District specialist

 Teacher Assistant/Aid  Administrator  Outside specialist  Law enforcement officer

 Other __________

When during the school day should pedestrian safety be taught?

During regular class time  During physical education  Before/after school program

 Recess  Never  Other ______________

Comments:________________________________________________________________________________________________________________________________________________________________________________________________

NHTSA Form 1215

NHTSA Form 1215 Page 4