Form NHTSA Form 1199 NHTSA Form 1199 Welcome Screen

OMB No. 2127-XXXX

Expiration Date: XX/XX/201X

National Highway Traffic Safety Administration (NHTSA)

U.S. Department of Transportation

Survey of Young Drivers

Thank you for taking a few minutes to complete this survey. The information you provide will contribute to what has been one of the most successful programs in improving the public welfare in the United States. Traffic safety programs have saved thousands of lives and prevented countless injuries. Their success has been dependent on the quality of information used to design the programs. NHTSA is conducting this survey to learn what people your age think and do when driving and riding in motor vehicles. Results will be used to improve ways of preventing crashes and injuries that continue to take a heavy toll on young people and their families.

The survey is voluntary and will take 15 minutes to complete. The information you provide will be kept separate from the information used to contact you so that your survey responses are treated as anonymous. Survey results will only be distributed as summary statistics that could not be used to identify anyone.

[Because you are under the age of 18, one of your parents, or a guardian if no parent is present, must give written consent for you to participate in the survey. Click Parent/Guardian for further instructions.] Parent/Guardian

Please answer the questions as accurately as you can. You don’t have to answer a question if it makes you uncomfortable. But remember that your answers will always be kept strictly private, and it’s important for the survey to obtain a full picture in order to develop effective ways of improving safety.

As an expression of appreciation, NHTSA is providing $X for completion and submission of the survey. Instructions are provided at point of submission.

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Paperwork Reduction Act Burden Statement: Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to, 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. The average amount of time to complete this survey is 40 minutes. All responses to this collection of information are voluntary. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590

NHTSA Form 1199