Form NHTSA Form 1084 B NHTSA Form 1084 B Distracted Driving Intercept Survey

OMB # 2127-0665 Expiration Date: March 31, 2016

Appendix C – Distracted Driving Intercept Screener and Survey

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 # 2127-0665. Public reporting for this collection of information is estimated to be approximately 5 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.

Survey Administrator Screening Questionnaire

Hello, I'm __________________ distributing surveys for the U.S. Department of Transportation. Several Driver Licensing Offices are participating in a study about traffic safety. We are looking for drivers 18 years and over to complete a 5 minute survey. Participation is voluntary and anonymous. [Note to survey administrator: Record respondent’s response regarding age and licensure status below and proceed as appropriate depending on response].

IS.1) Thank you. First, are you 18 years old or older?

1. Yes (continue)

2. No (Thank you for your time. We need volunteers 18 and over.)

IS.2) Are you a licensed driver?

1. Yes

2. No (Thank you for your time. We need volunteers who are licensed drivers.)

IS.3) FROM OBSERVATION, NOTE SEX OF RESPONDENT

1. Male

2. Female

IF QUALIFIED TO PARTICIPATE – Would you like to participate? [Survey administrator response options] [If respondent would like to participate] Ok, thank you. I now have a brief survey for you to complete while you wait for your license. Would you mind completing the survey and dropping it in the box over there [indicate where to drop surveys]. [If respondent decides against participation] Ok, thank you so much for your time, have a good day.

IF NOT QUALIFIED TO PARTICIPATE – Thank you so much for your time, have a good day.

[Note to survey administrator: If respondent asks for more information about the data collection, provide the following]

• Participation in voluntary.

• Participation is anonymous, and we will not collect any personal information that would allow anyone to identify you.

• Please note that 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 currently valid OMB control number.

• The OMB control number for this collection is 2127-0665.

Intercept Survey

Several Driver Licensing Offices are participating in a study about traffic safety and unsafe driving. Your answers to the following questions are voluntary and anonymous. Please complete the survey and drop it in the box.

This collection of information is voluntary and will be used for statistical purposes only so that we may develop and evaluate programs designed to reduce the number of traffic-related injuries and deaths. Public reporting burden is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Your participation is anonymous, and we will not collect any personal information that would allow anyone to identify you. Please note that 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 currently valid OMB control number. The OMB control number for this collection is # 2127-0665.

1. Your sex: [] Male [] Female

2. Your age: [] Under 18 [] 18-20 [] 21-34 [] 35-49 [] 50-59 [] 60 Plus

3. Do you consider yourself Hispanic or Latino? [] Yes [] No

4. Your race: Check all that apply: [] American Indian or Alaska Native [] Asian [] Black or African American

[] Native Hawaiian or other Pacific Islander [] White

5. What is the highest grade or year of school you completed?

[]Less than HS

[]HS or equivalent

[]Some college but no degree

[]College graduate and beyond

6. What city or town, and state do you currently live in (Select 1 only)?

[] Bethel	[] East Lyme	[] Monroe	[] Newtown	[] Ridgefield
[] Brookfield	[] Groton	[] Montville	[] Norwich	[] Stonington
[] Danbury	[] Ledyard	[] New London	[] Redding	[] Waterford
[] Other (Specify)________________________________________________________________________

7. About how many miles did you drive last year?

[] Less than 5,000 [] 5,000 to 10,000 [] 10,001 to 15,000 [] More than 15,000

8. What type of vehicle do you drive most often?

[] Passenger car [] Pickup truck [] Sport utility vehicle [] Mini-van [] Full-van [] Other

9. How often do you talk on a hand-held cellular phone when you drive?

[] Always [] Nearly always [] Sometimes [] Seldom [] Never

10. How often do you type, read, or send text messages or emails on a hand-held cellular phone or device when you drive?

[] Always [] Nearly always [] Sometimes [] Seldom [] Never

11. Do you think that it is important for police to enforce distracted driving laws? [] Yes [] No

12. What do you think the chances are of getting a ticket if you type, read, or send text messages on a hand-held cellular phone or device while driving?

[] Very likely [] Somewhat likely [] Neither likely nor unlikely [] Somewhat unlikely [] Very unlikely

13. Do you think the texting law in [State] is enforced?

[] Very strictly [] Somewhat strictly [] Neither strictly nor loosely [] Somewhat loosely [] Very loosely

14. Have you received a ticket for typing, reading, or sending a text message while driving?

Ever: [] Yes [] No In the past month: [] Yes [] No

15. Have you received a ticket for distracted or inattentive driving?

Ever: [] Yes [] No In the past month: [] Yes [] No

16. In the PAST MONTH, have you seen police on the roads you normally drive?

[] More than usual [] About the same [] Less than usual [] Never see them

17. Have you recently read, seen or heard any messages about the enforcement of texting and driving in [State]?

[] Yes [] No

If yes, where did you see or hear about it? (Check all that apply):

[] Newspaper [] Radio [] TV [] Billboards [] Brochure [] Online [] Police Enforcement [] Other

If yes, what did it say? ___________________________________________________________

18. Do you know the name of any distracted driving program(s) in [State]? (check all that apply):

[] Slogan #1 [] Slogan #2 [] Slogan #3 [] Slogan #4

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