NHTSA Form 1020A Version A Questionnaire

OMB No. 2127-0645

Expiration Date: X/XX/2017

Q1 How often do you drive a motor vehicle……………?

1 Every day

2 Almost every day

3 A few days a week

4 A few days a month

5 A few days a year, or

10 Never SKIP TO Q30

12 Other (SPECIFY)

98 Don’t know

Q1a How often do you drive a motor vehicle at night, after 9:00 pm………….?

1 Every day

2 Almost every day

3 A few days a week

4 A few days a month

5 A few days a year, or do you

10 Never drive after 9:00 at night

12 Other (SPECIFY)

98 Don’t know

Q2 Not including driving to and from work, do you at least sometimes drive a vehicle as part of a job or business?

1 Yes

2 No SKIP TO Q5

3 Don’t work SKIP TO Q5

8 Don’t know SKIP TO Q5

Q3 How often do you drive a vehicle as part of a job or business……………?

1 Every day

2 Almost every day

3 A few days a week

4 A few days a month

5 A few days a year

10 Never drive as part of a job

12 Other (SPECIFY)

98 Don’t know

NHTSA Form 1020A

Q4 Does your company or business have a policy requiring seat belt use when driving on the job?

1 Yes

2 No SKIP TO Q5

8 Don’t know SKIP TO Q5

Q4a Is that a written policy?

1 Yes

2 No

8 Don’t know

Q5 Please think about all the driving you do, both personal and any job-related driving. Is the vehicle you drive most often a car, van, motorcycle, sport utility vehicle, pickup truck, or other type of truck? If you drive more than one vehicle and can’t decide which of them you drive most often, then answer for which of those vehicles you drove last.

1 Car or station wagon

2 Van or minivan

3 Motorcycle SKIP TO Q30

4 Sport utility vehicle

(Jeep/Explorer/Trooper/etc)

5 Pickup truck

6 Other type of truck (SPECIFY)

7 Other (SPECIFY)

8 Don’t know

THE FOLLOWING SEAT BELT QUESTIONS REFER TO DRIVER SIDE SEAT BELTS.

Q6 For the next series of questions, please answer only for the (car/truck/van/SUV) you said you usually drive. Do the seat belts in the front seat of the (car/truck/van/SUV) go across your shoulder only, across your lap only, or across both your shoulder and lap?

1 Across shoulder SKIP TO Q11

2 Across lap SKIP TO Q12

3 Across both

4 Vehicle has no belts SKIP TO Q25

8 Don’t know SKIP TO Q12

Q7 Are the shoulder and lap belt one piece or are they two separate belts?

1 One piece

2 Two separate belts

8 Don’t know

Q11 Shoulder belts are usually attached to the frame behind the driver’s left shoulder. In some vehicles, this attachment can be moved up or down to adjust the shoulder belt. Is this attachment adjustable in your vehicle?

1 Yes, adjustable

2 No, not adjustable SKIP TO Q12

8 Don’t know SKIP TO Q12

Q11a Have you ever tried to adjust it?

1 Yes

2 No SKIP TO Q11c

8 Don’t know SKIP TO Q12

Q11b Were you able to make the shoulder belt more comfortable by adjusting it?

1 Yes SKIP TO Q12

2 No SKIP TO Q12

3 Could not adjust it SKIP TO Q12

8 Don’t know SKIP TO Q12

Q11c Why have you never tried to adjust it? CHECK ALL THAT APPLY.

1 It already fits

2 It’s comfortable enough

3 Someone adjusted it for me

4 Never thought about it

10 Hard to adjust

11 Automatic/self adjusting

12 Don’t wear seat belt

13 Didn’t know it was adjustable

14 Other (SPECIFY)

98 Don’t know

Q12 When driving this (car/truck/van/SUV), how often do you wear your seat belt?

1 All of the time

2 Most of the time

3 Some of the time

4 Rarely or

5 Never

8 Don’t know

Q14 When was the last time you did NOT wear your seat belt when driving?

1 Today

2 Within the past week

3 Within the past month

4 Within the past 12 months

5 A year or more ago

6 Other (SPECIFY)

8 Don’t know

GO TO Q14a IF DON’T KNOW IN Q14, ELSE SKIP TO Q15

Q14a Has there been any occasion in the past 12 months when you did not wear your seat belt when driving?

1 Yes

2 No

8 Don’t know

IF Q2=YES AND Q12 EQ 1-4 GO TO Q15, ELSE GO TO Q17

Q15 Are you more likely, less likely or just as likely to wear your seat belt when driving on the job as compared to when driving for personal use?

1 More likely

2 Less likely SKIP TO Q16B

3 Just as likely SKIP TO Q17

8 Don’t know SKIP TO Q17

Q16a Why are you MORE likely to wear your belt when driving on the job? CHECK ALL THAT APPLY.

1 Company policy

2 Increased awareness of safety

3 Seat belt law

4 Don’t want ticket

5 Habit/always wear it

6 Drive long distances

7 Have passengers/client in vehicle with me

8 Insurance reasons

9 Driving in heavy traffic

10 Driving larger vehicle

11 More highway driving

12 Other (SPECIFY)

98 Don’t know

IF Q15=2 THEN ANSWER Q16B; ELSE SKIP TO Q17

Q16b Why are you LESS likely to wear your belt when driving on the job? CHECK ALL THAT APPLY.

1 Not company policy/practice

2 Don’t drive on roads/main streets

3 Don’t like being told what to do

4 Don’t like wearing them

5 Habit/never/rarely wear it

6 Drive short distances

7 In/out of vehicle all the time/type of work/equipment gets in the way

8 Driving slowly

9 Don’t have passengers with me

10 Seat belt broken/not working

13 Other (SPECIFY)

98 Don’t know

Q17 In the past 12 months, has your use of seat belts when driving increased, decreased, or stayed the same?

1 Increased

2 Decreased SKIP TO Q19

3 Stayed the same SKIP TO Q19

4 I’m a new driver/didn’t drive 12 months ago SKIP TO Q19

8 Don’t know SKIP TO Q19

Q18 What caused your use of seat belts to increase……? CHECK ALL THAT APPLY. RANDOMIZE ORDER.

		Yes	No	Don’t Know
a.	I became more aware of safety issues	1	2	8
b.	The seat belt law	1	2	8
c.	I didn’t want to get a ticket	1	2	8
d.	I got a seat belt ticket/warning	1	2	8
e.	I was in a crash	1	2	8
f.	Someone I know was in a crash	1	2	8
g	Other people encouraged or pressured me to use seat belts	1	2	8
h.	I wanted to set a good example for children	1	2	8
i.	Someone I know got a ticket	1	2	8
j.	Other (SPECIFY)	1	2	8

IF Q12 EQ 1-4 GO TO Q19, ELSE SKIP TO Q21.

Q19 Below are a list of reasons why people might wear a seat belt. For each reason given, please indicate, yes or no, whether it applies to you. When I wear my seat belt, I do so because........ RANDOMIZE ORDER

		Yes	No	Don’t Know
a.	It’s a habit	1	2	8
b.	I don’t want to get a ticket	1	2	8
c.	I’m uncomfortable without it	1	2	8
d.	Others want me to wear it	1	2	8
e.	It’s the law	1	2	8
f.	I want to avoid serious injury or death	1	2	8
g.	I want to set a good example for others	1	2	8
h.	The people I’m with are wearing seat belts	1	2	8
i.	My (car/truck/van/SUV) has a bell, buzzer, or light that reminds me	1	2	8

Q19j Are there any other reasons why you wear your seat belt?

1 Yes

2 No SKIP TO Q20

8 Don’t know SKIP TO Q20

Q19j1 What are the other reasons why you wear your seat belt?

(SPECIFY)

Q20 Of the reasons you just gave for wearing your seat belt, which is the most important? SINGLE RECORD.

1 It’s a habit

2 I don’t want to get a ticket

3 I’m uncomfortable without it

4 Others want me to wear it

5 It’s the law

6 I want to avoid serious injury or death

7 I want to set a good example for others

8 The people I’m with are wearing seat belts

9 My (car/truck/van/SUV) has a bell, buzzer, or light that reminds me

10 Other (SPECIFY)

23 Can’t say one is most important/all are important

98 Don’t know

IF Q12 EQ 2-5 OR Q14 EQ 1-4 OR Q14A EQ 1 GO TO Q21, ELSE SKIP TO Q22A

Q21 Please indicate if you agree or disagree with the following statements concerning your use of seat belts. Sometimes I do not wear my seat belt because........ RANDOMIZE ORDER

		Yes	No	Don’t Know
1.	I’m only driving a short distance	1	2	8
2.	I’m driving in light traffic	1	2	8
3.	I’m in a rush	1	2	8
4.	I forgot to put it on	1	2	8
5.	I don’t want my clothes to get wrinkled	1	2	8
6.	The seat belt is uncomfortable	1	2	8
7.	The probability of being in a crash is too low	1	2	8
8.	The people I am with are not wearing seat belts	1	2	8
9.	I don’t like being told what to do	1	2	8
j.	Seat belts sometimes cause injuries	1	2	8
k.	I’m driving on low speed roadways	1	2	8

Q21m Are there any other reasons why you sometimes do not wear your seat belt?

1 Yes

2 No SKIP TO Q22

8 Don’t know SKIP TO Q22

Q21k1 What are the other reasons why you sometimes do not wear your seat belt?

(SPECIFY)

Q22 Of the reasons you just gave for not wearing your seat belt, which is the most important? SINGLE RECORD.

1 I’m only driving a short distance

2 I’m driving in light traffic

3 I’m in a rush

4 I forgot to put it on

5 I don’t want my clothes to get wrinkled

6 The seat belt is uncomfortable

7 The probability of being in a crash is too low

8 The people I am with are not wearing seat belts

9 I don’t like being told what to do

10 Seat belts sometimes cause injuries

11 I’m driving on low speed roadways

13 Can’t say one is most important/all are important

16 Other (SPECIFY)

98 Don’t know

Q22a When driving at night, are you more likely, less likely, or just as likely to wear your seat belt compared to when driving during the day?

1 More likely

2 Less likely

3 Just as likely

4 Don’t drive at night

8 Don’t know

Q23 Is there anything that you particularly dislike or find annoying about wearing your seat belt?

1 Yes

2 No SKIP TO Q25

8 Don’t know SKIP TO Q25

Q24 What is it that you dislike or find annoying? CHECK ALL THAT APPLY.

1 Seat belts are uncomfortable

2 Seat belts are a nuisance/hassle/annoyance

3 Feel restricted/too confining/constricting

4 Pressure on my neck/chokes me/cuts across my neck

5 Pressure on my shoulder/shoulder strap too tight

6 Pressure on my chest/Strap doesn’t fit my chest

7 Irritates/chafes my skin/rash

8 Wrinkles my clothes

9 Other (SPECIFY)

98 Don’t know

Q25 The next series of questions ask about children riding in motor vehicles. How many children age 15 or younger are living in your household at least half of the time or consider it their primary residence?

_____ Children age 15 or younger

98. Don’t know

IF Q25=0 OR 98 SKIP TO Q30

Q26. How old is (this child/the youngest child)?

_____ Years old

0. Under 1

IF Q26=0-12 ANSWER Q27, ELSE SKIP TO Q30

Q27 Think about all the times this child rode with you in the past thirty days, both with and without other passengers. How often would you say that the child rode in the front seat…..?

1 All trips

2 Most trips

3 About half your trips

4 Fewer than half your trips, or

5 Never

7 Don’t know

IF Q26 = 0 SKIP TO Q30

Q28 Compared to 12 MONTHS ago, is this child more likely to ride in the front seat when you drive, as likely to ride in the front seat, or less likely to ride in the front seat?

1 More likely to ride in front seat

2 As likely to ride in front seat SKIP TO Q30

3 Less likely to ride in front seat SKIP TO Q28b

4 Don’t currently drive with child SKIP TO Q30

5 Didn’t drive with child 12 months ago SKIP TO Q30

8 Don’t know SKIP TO Q30

Q28a Why is this child more likely to ride in the front seat when you drive? CHECK ALL THAT APPLY

1 Child is older/larger SKIP TO Q30

2 Child and I are the only ones in vehicle SKIP TO Q30

3 The child prefers the front SKIP TO Q30

4 Child likes to sit by me SKIP TO Q30

5 I want to be able to see/reach child SKIP TO Q30

6 No other place for child in vehicle SKIP TO Q30

12 Other (SPECIFY) SKIP TO Q30

98 Don’t know SKIP TO Q30

Q28b Why is this child less likely to ride in the front seat when you drive? CHECK ALL THAT APPLY.

1 Safer in back

2 Danger from airbags

3 Child prefers back

4 Child’s car seat is in back

5 No other place for child in vehicle

6 It’s the law

7 Child is too young/small

12 Other (SPECIFY)

98 Don’t know

Q30 How often do you ride as a passenger in any kind of car, van or truck ………?

1 Almost every day

2 A few days a week

3 A few days a month

4 A few days a year or

5 Never SKIP TO Q40

8 Don’t know

Q31 When you are a passenger, do you usually ride in the front seat or the back seat?

1 Front seat

2 Back seat

8 Don’t know

Q32 When riding as a passenger in the front seat how often do you wear your seat belt?

1 All of the time

2 Most of the time

3 Some of the time

4 Rarely or

5 Never

6 Never ride in front seat

8 Don’t know

Q33 When riding as a passenger in the back seat how often do you wear your seat belt?

1 All of the time

2 Most of the time

3 Some of the time

4 Rarely or

5 Never

6 Never ride in back seat

8 Don’t know

IF Q1 NE NEVER (10) AND Q5 NE MOTORCYCLE, SKIP TO Q40.

IF Q1=NEVER (10) AND Q32 NE 1‑4 AND Q33 NE 1‑4, SKIP TO Q36.

IF Q5=MOTORCYCLE AND Q32 NE 1‑4 AND Q33 NE 1‑4, SKIP TO Q36

Q34 Below are a list of reasons why people might wear a seat belt. For each reason given, please indicate, yes or no, whether it applies to you. When I wear my seat belt, I do so because........ RANDOMIZE ORDER

		Yes	No	Don’t Know
a.	It’s a habit	1	2	8
b.	I don’t want to get a ticket	1	2	8
c.	I’m uncomfortable without it	1	2	8
d.	Others want me to wear it	1	2	8
e.	It’s the law	1	2	8
f.	I want to avoid serious injury	1	2	8
g.	I want to set a good example for others	1	2	8
h.	The people I’m with are wearing seat belts	1	2	8
i.	My (car/truck/van/SUV) has a bell, buzzer, or light that reminds me	1	2	8

Q34j Are there any other reasons why you wear your seat belt?

1 Yes

2 No SKIP TO Q35

8 Don’t know SKIP TO Q35

Q34j1 What are the other reasons why you wear your seat belt?

(SPECIFY)

Q35 Of the reasons you just gave me for wearing your seat belt, which is the most important? SINGLE RECORD.

1 It’s a habit

2 I don’t want to get a ticket

3 I’m uncomfortable without it

4 Others want me to wear it

5 It’s the law

6 I want to avoid serious injury

7 I want to set a good example for others

8 The people I’m with are wearing seat belts

9 My (car/truck/van/SUV) has a bell, buzzer or light that reminds me

18 Other (SPECIFY)

19 Can’t say one is most important/all are important

98 Don’t know

IF Q32 = 2-5 OR Q33 = 2-5 THEN GO TO Q36, ELSE SKIP TO Q38

Q36 Please indicate if you agree or disagree with the following statements concerning your use of seat belts. Sometimes I do not wear my seat belt because........ RANDOMIZE ORDER

		Yes	No	Don’t Know
a.	I’m only riding a short distance	1	2	8
b.	I’m riding in light traffic	1	2	8
c.	I’m in a rush	1	2	8
d.	I forgot to put it on	1	2	8
e.	I don’t want my clothes to get wrinkled	1	2	8
f.	The seat belt is uncomfortable	1	2	8
g.	The probability of being in a crash is too low	1	2	8
h.	The people I am with are not wearing seat belts	1	2	8
i.	I don’t like being told what to do	1	2	8
j.	Seat belts sometimes cause injuries	1	2	8
k.	I’m riding on low speed roadways	1	2	8

Q36l Are there any other reasons why you sometimes do not wear your seat belt?

1 Yes

2 No SKIP TO Q37

8 Don’t know SKIP TO Q37

Q361 What are the other reasons why you sometimes do not wear your seat belt?

(SPECIFY)

Q37 Of the reasons you just gave for not wearing your seat belt, which is the most important? SINGLE RECORD.

1 I’m only riding a short distance

2 I’m riding in light traffic

3 I’m in a rush

4 I forget to put it on

5 I don’t want my clothes to get wrinkled

6 The seat belt is uncomfortable

7 The probability of being in a crash is too low

8 The people I am with are not wearing seat belts

9 I don’t like being told what to do

10 Seat belts sometimes cause injuries

11 I’m driving on low speed roadways

12 Can’t say one is most important/all important

13 Other (SPECIFY)

98 Don’t know

Q38 Is there anything that you particularly dislike or find annoying about wearing your seat belt?

1 Yes

2 No SKIP TO Q40

8 Don’t know SKIP TO Q40

Q39 What is it that you dislike or find annoying? CHECK ALL THAT APPLY.

1 Seat belts are uncomfortable

2 Seat belts are a nuisance/hassle/annoyance

3 Feel restricted/too confining/constricting

4 Pressure on my neck/chokes me/cuts across my neck

5 Pressure on my shoulder/shoulder strap too tight

6 Pressure on my chest/Strap doesn’t fit my chest

7 Irritates/chafes my skin/rash

8 Wrinkles my clothes

9 Other (SPECIFY)

98 Don’t know

Q40 How do you feel about laws that require drivers and front seat passengers to wear seat belts? Do you favor these laws a lot, do you favor them some or do you not favor these laws at all?

1 Favor a lot

2 Favor some

3 Not favor at all SKIP TO Q44

8 Don’t know SKIP TO Q44

Q41 Do you think that seat belt laws should also apply to back seat ADULT passengers?

1 Yes

2 No

3 Depends on age of the passenger

4 Depends on type of vehicle

9 Other (SPECIFY)

98 Don’t know

Q42 Do you favor or oppose fines for drivers who do not wear seat belts?

1 Favor

2 Oppose SKIP TO Q43

8 Don’t know SKIP TO Q43

Q42a What do you think the minimum fine should be for a seat belt violation?

_____ Amount of fine

9998 Don’t know

Q43 Do you favor or oppose receiving points against a license as a penalty for seat belt violations?

1 Favor

2 Oppose

3 Depends on past violations

8 Don’t know

Q44 I’d like you to think about someone you know who doesn’t wear seat belts all of the time. If that person were stopped and fined (AMOUNT OF FINE IN STATE) for not wearing seat belts, would this person definitely wear seat belts more often, probably wear seat belts more often, or probably not change his or her seat belt wearing habits?

1 Definitely wear more often

2 Probably wear more often

3 Probably not change seat belt wearing habits

4 Other (SPECIFY)

8 Don’t know

Q45 Suppose you get a ticket for not wearing your seat belt. Which of the following statements better describes your likely reaction?

1 I deserve the ticket because I broke the law, or

2 I do NOT deserve the ticket because wearing a seat belt should be a personal choice

8 Don’t know

Q46 The next questions are about seat belt laws in your State. Does (STATE) have a law requiring seat belt use?

1 Yes

2 No SKIP TO Q49

8 Don’t know SKIP TO Q49

Q47 Who is required to wear seat belts according to your State law?

		Yes	No	Don’t Know
a.	Drivers	1	2	8
b.	Children in the front seat	1	2	8
c.	Children in the back seat	1	2	8
d.	Adult passengers in the front seat	1	2	8
e.	Adult passengers in the back seat	1	2	8

Q48 According to your State law, can police stop a vehicle if they observe a seat belt violation or do they have to observe some other offense first in order to stop the vehicle?

1 Can stop just for seat belt violation

2 Must observe another offense first in order to stop vehicle

8 Don’t know

Q49 In your opinion, SHOULD police be allowed to stop a vehicle if they observe a seat belt violation when no other traffic laws are being broken?

1 Should be allowed to stop SKIP TO Q50

2 Should not

8 Don’t know SKIP TO Q50

Q49a Most other traffic laws allow police to stop the vehicle whenever they see a violation. Why do you think seat belt violations should be treated differently from other traffic violations? CHECK ALL THAT APPLY.

1 Don’t pose a risk to others

2 Not as serious a violation

3 Police may abuse it

4 Should be a personal choice/not a good law/infringe on rights

5 Can’t always tell if seat belt is on/Can be mistaken

6 Should only apply to children

7 Police should be doing more important things

10 Other (SPECIFY)

98 Don’t know

IF Q1=10 (NEVER) , SKIP TO Q51

Q50 In the past twelve months, since (MONTH) of last year, have you been stopped by police for ANY traffic-related reason while driving?

1 Yes

2 No SKIP TO Q51

8 Don’t know SKIP TO Q51

Q50a Were you wearing a seat belt when you were stopped? IF STOPPED MORE THAN ONCE IN PAST 12 MONTHS, ANSWER FOR MOST RECENT TIME.

1 Yes SKIP TO Q50e

2 No

8 Don’t know SKIP TO Q50e

Q50b Did you receive a ticket for violating seat belt laws?

1 Yes SKIP TO Q50d

2 No

8 Don’t know

Q50c Did you receive a warning for violating seat belt laws?

1 Yes

2 No

8 Don’t know

Q50d Did you receive a ticket for some other traffic violation?

1 Yes SKIP TO Q51

2 No SKIP TO Q51

8 Don’t know SKIP TO Q51

Q50e Did you receive a ticket for any traffic violation?

1 Yes

2 No

8 Don’t know

IF YES IN Q50b SKIP TO Q52

Q51 Have you ever received a ticket for not wearing seat belts?

1 Yes

2 No

8 Don’t know

IF YES IN Q50c SKIP TO Q52a

Q52 Have you ever received a warning for not wearing seat belts?

1 Yes

2 No

8 Don’t know

IF YES IN Q50b, Q50c, Q51 OR Q52 GO TO Q52a, OTHERWISE SKIP TO Q53

Q52a After you received the seat belt (ticket/warning), did you start wearing your seat belts more often, less often, or was there no change in how often you wore them?

1 Wore seat belt more often

2 Wore seat belt less often

3 No change in how often wore seat belt

8 Don’t know

IF Q1=NEVER (10) SKIP TO Q55 ELSE GO TO Q53

Q53 Assume that you do not wear your seat belt AT ALL while driving over the next six months. How likely do you think you will be to receive a ticket for not wearing a seat belt?

1 Very likely

2 Somewhat likely

3 Somewhat unlikely

4 Very unlikely

8 Don’t know

Q55 For each of the following statements, please indicate whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with the statement. ROTATE LIST.

Strongly Somewhat Strongly Somewhat

Agree Agree Disagree Disagree DK

a.	Seat belts are just as likely to harm you as help you.	1	2	3	4	8
b.	Police in my community generally do not bother to write tickets for seat belt violations.	1	2	3	4	8
c.	An accident close to home is usually not as serious as an accident farther away.	1	2	3	4	8
d.	If I were in an accident, I would want to have my seat belt on.	1	2	3	4	8
e.	Most motor vehicle accidents happen within five miles of home.	1	2	3	4	8
f.	I would feel self-conscious around my friends if I wore a seat belt and they did not.	1	2	3	4	8
g.	I have a habit of wearing a seat belt because my parents insisted I wear them when I was a child.	1	2	3	4	8
h.	It is just as important for police to enforce seat belt laws as it is for police to enforce other traffic laws	1	2	3	4	8
i.	Putting on a seat belt makes me worry more about being in an accident.	1	2	3	4	8

Next are a few questions about speed limits.

Q57 In general, do you think most highway speed limits are too ……?

1 Too low

2 Too high

3 About right

8 Don’t know

Q58 How about residential speed limits or those not on a highway? Do you think they are …?

1 Too low

2 Too high

3 About right

8 Don’t know

Q59 Would you say the driving of most other drivers is........?

1 Excellent

2 Very good

3 Good

4 Fair or

5 Poor

8 Don’t know

IF Q1=NEVER (10) SKIP TO Q67 ELSE GO TO Q60

Q60 How often do you feel pressure from other drivers to go faster than the speed limit?

1 Very often

2 Often

3 Rarely

4 Never

8 Don’t know

Q61 Which statement best describes your highway driving? (1) I tend to pass other cars more often that other cars pass me, or (2) Other cars tend to pass me more often.

1 I tend to pass other cars more often than other

cars pass me

2 Other cars tend to pass me more often

3 Other (SPECIFY)

8 Don’t know

Q62 In general, how fast do you drive on highways?

_____ Miles per hour

997. I don’t drive on highways

998. Don’t know

Next are a few questions about airbags.

IF Q1=NEVER (10) OR Q5=MOTORCYCLE, SKIP TO Q67 ELSE GO TO Q63

Q63 Does the (car/truck/van/SUV) you normally drive have an air bag?

1 Yes

2 No SKIP TO Q67

8 Don’t know SKIP TO Q67

Q64 Does the (car/truck/van/SUV) you normally drive have an air bag ………?

Yes No Don’t

Know

a. In front of the driver 1 2 8

b. In front of where a passenger would sit in the front seat 1 2 8

c. In the side of the vehicle near the front seat 1 2 8

d. In the ceiling of the vehicle above the front seat 1 2 8

e. In the side of the vehicle near the back seat 1 2 8

f. In the ceiling of the vehicle above the back seat 1 2 8

g. Anywhere else (SPECIFY) 1 2 8

IF Q1=10 ANSWER Q67 AS A PASSENGER. OTHERWISE ANSWER AS A DRIVER

Q67 Please indicate whether you agree or disagree with the following statement. If my car has a (driver/passenger) side airbag, I don’t need to wear my seat belt when (driving/riding).

1 Agree

2 Disagree

8 Don’t know

Q78 Next are a few questions about alcohol use. During the past 30 days have you had at least one drink of any alcoholic beverage, including liquor, beer, wine or wine coolers?

1 Yes SKIP TO Q80

2 No

8 Don’t know

Q79 Did you drink any alcoholic beverages at all during the past 12 months?

1 Yes SKIP TO Q81

2 No SKIP TO Q86

8 Don’t know SKIP TO Q86

Q80 How many days out of the past 30 days did you drink alcoholic beverages?

____ Days (RANGE=0-30)

98. Don’t know

Q81 On the average, how many drinks did you typically have on the days you drank?

_____ Drinks

98. Don’t know

IF Q1=NEVER (10) OR Q78=NO OR DK, SKIP TO Q86 ELSE GO TO Q82

Q82 During the past 30 days, have you driven a vehicle after you had been drinking alcohol?

1 Yes

2 No SKIP TO Q86

8 Don’t know SKIP TO Q86

Q83 How many days out of the past 30 days did you drive after drinking alcoholic beverages?

_____ Days (RANGE=0-30)

98. Don’t know

Q84 In the past 30 days, have you driven a vehicle when you thought you might have consumed too much alcohol to drive safely?

1 Yes

2 No

8 Don’t know

Q86 Have YOU ever been injured in a motor vehicle accident? This includes being injured as a driver, as a passenger, as a motorcyclist, as a pedestrian hit by a motor vehicle, and as a bicyclist hit by a motor vehicle. Only count injuries that required medical attention.

1 Yes

2 No SKIP TO Q97

8 Don’t know SKIP TO Q97

Q87 How many times have you been injured in a motor vehicle accident?

_____ Number of times

98. Don’t know

Q88 How long ago did (that/your most recent) accident occur? ONLY ACCIDENTS THAT REQUIRED MEDICAL ATTENTION

_____ Years ago (RANGE=0-97)

0. Within the past 12 months

98 Don’t know

Q88a Did (that/the most recent) accident happen less than 5 miles from where you lived at the time of the accident?

1 Yes, less than 5 miles

2 No, 5 miles or more away

8 Don’t know

Q89 In that accident, were you a ….?

1 Driver

2 Passenger

3 Pedestrian

4 Bicyclist

5 Motorcyclist

6 Other (SPECIFY)

8 Don’t know

IF Q89=3, 4, OR 5 SKIP TO Q91

Q90 Were you wearing your seat belt at the time of the accident?

1 Yes

2 No

8 Don’t know

Q91 At which of the following were you treated for your injuries? Were you treated at........?

		Yes	No	Not Sure
a.	A hospital emergency room	1	2	8
b.	A doctor’s office	1	2	8
c.	A clinic	1	2	8
d.	The accident scene	1	2	8
e.	Somewhere else (SPECIFY)	1	2	8

Q92 Were you transported from the accident scene by ambulance or helicopter?

1 Yes, ambulance (or rescue vehicle)

2 Yes, helicopter

3 No, neither

4 Don’t know

Q93 Were you hospitalized?

1 Yes

2 No SKIP TO Q94

8 Don’t know SKIP TO Q94

Q93a How long were you hospitalized?

_____ Days _____ Hours Don’t know

Q94 Did you receive any continuing or follow-up treatment for your injuries?

1 Yes

2 No SKIP TO Q95

8 Don’t know SKIP TO Q95

Q94a Where did you receive this follow-up treatment? Was it at........?

		Yes	No	Don’t Know
a.	A doctor’s office	1	2	8
b.	A physical therapist’s office	1	2	8
c.	A clinic	1	2	8
d.	A hospital	1	2	8
e.	A chiropractor	1	2	8
f.	Somewhere else (SPECIFY)	1	2	8

Q95 Did your injuries from that accident prevent you from performing any of your normal activities (work, school, household) for…..?

	Yes	No	Don’t Know
a. At least a week	1	2	8
b. More than a week but less than a year	1	2	8
c. A year or more	1	2	8

Q96 Have you ever received injuries from a motor vehicle accident that prevented you from performing any of your normal activities (work, school, household) for …..?

	Yes	No	Don’t Know
a. At least a week	1	2	8
b. More than a week but less than a year	1	2	8
c. A year or more	1	2	8

IF YES IN Q86 SKIP TO Q98

Q97 Were you ever a driver or a passenger in a motor vehicle accident that involved death or injuries requiring medical attention?

1 Yes

2 No

8 Don’t know

Q98 People have different beliefs about their own chances of survival in a crash. Do you agree or disagree that if it is your time to die, you’ll die, so it doesn’t matter whether you wear your seat belt?

1 Agree

2 Disagree

8 Don’t know

There are just a few remaining questions and then the survey will be done.

Q99 Are you a male or a female?

1 Male

2 Female

Q100 What is your age?

_____ Years old

SKIP TO Q102 IF RECEIVED Q25

Q101 How many children age 15 OR YOUNGER are living in your household at least half of the time or consider it their primary residence?

_____ Children

98 Don’t Know

Q102 Do you consider yourself to be Hispanic or Latino?

1 Yes

2 No

Q103 Which of the following racial categories describes you? You may select more than one. CHECK ALL THAT APPLY.

1 American Indian or Alaskan Native

2 Asian

3 Black or African‑American

4 Native Hawaiian or Other Pacific Islander

5 White

Q105 What is the highest grade or year of school you completed?

8 8th grade or less

9 9th grade

10 10th grade

11 11th grade

12 12th grade/GED

13 Some college

14 College graduate or higher

Q106 Which of the following categories best describes your total household income before taxes in 2013? (Includes the income of all persons in the household.) Was your total household income........?

1 Less than $5,000

2 $5,000 to $14,999

3 $15,000 to $29,999

4 $30,000 to $49,999

5 $50,000 to $74,999

6 $75,000 to $99,999

7 $100,000 or more

8 Don’t know

In order to better understand driver and rider characteristics, we’d like to ask you about your height and weight.

Q108 About how tall are you without shoes?

_____ Feet _____ Inches

Q109 What is your weight?

_____ Pounds

That completes the survey. Thank you very much for your time and cooperation.

26