Form MCSA-5868 Motorcoach Passenger Survey: Pre-Trip Safety Awareness a



OMB No.: 2126-####  Expiration: ##/##/####

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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, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590-0001.

United States Department of Transportation
Federal Motor Carrier Safety Administration

Motorcoach Passenger Survey:
Pre-Trip Safety Awareness and Emergency Preparedness Information

FORM MCSA-5868
Date and Time of Trip:

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USDOT Number:

Vehicle Number:

Origin of Trip:

Survey Location:

Survey Participant Demographics: Gender:

Male

pm

Motorcoach Company:
License Plate:
No Response (skip rest of form)

Age:

Female

18-24

25-34

35-44

45-54

55-64

65+

1. Did the driver provide safety information during your trip? (Check only one.)
YES

NO

• If “Yes,” when or during what phase of your trip did you receive this safety information? (Check all that apply.)
Pre-trip

Layover

Destination

(a) Please describe the content of the safety information. (Check all that apply.)
Seat Belts

Emergency Exits

Fire Extinguisher

Emergency Contact

Driver Direction

Restroom Emergency Push Button or Switch

Avoiding Slips and Falls

Other: __________________________________________________________________________________________________________________
(b) What method(s) was/were used to provide the safety information? (Check all that apply.)
Driver Presented Briefing
Printed Pamphlet

Prerecorded Audio

Prerecorded Video

Other: ____________________________________________________________________________________

2. How often have you taken trips aboard motorcoaches within the last year? (Check only one.)
Once

2-5

6-10

11-25

More than 25

3. How many times have you received safety information during motorcoach trips within the last year? (Check only one.)
Never

Sometimes

About Half the Time

Most of the Time

Always

4. Do you feel safer riding in a motorcoach as a result of receiving safety information? (Check only one.)
YES

NO

Uncertain

5. Is there additional information that the safety information briefing should include? (Check only one.)
YES

NO

• If
  “Yes,” what additional information
would you suggest for improvement?

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

FORM MCSA-5868 • Page 1 of 1