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 Q8
12 Other (SPECIFY)
98 Don’t know
Q2 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 Q8
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.
Q3 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 Q5
2 Across lap SKIP TO Q5
3 Across both
4 Vehicle has no belts SKIP TO Q8
8 Don't know SKIP TO Q5
Q4 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
NHTSA Form 1020B
Q5 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
Q6 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
8 Don’t know
GO TO Q7 IF DON’T KNOW IN Q6, ELSE SKIP TO Q8
Q7 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
The next series of questions asks about children living in your household. The questions are being asked in order to relate the information to later questions about how children ride in motor vehicles.
Q8 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
IF Q1=NEVER, SKIP TO Q89
IF ONE OR MORE IN Q8, ANSWER Q9a/b/c FOR EACH CHILD, ELSE GO TO Q12
NOTE: TWINS (TRIPLETS, ETC.) ARE ENTERED SEPARATELY, YOUNGEST FIRST
Q9a How old is (this child/the youngest child)?
0 Newborn/less than 1 year old
1 1 year old
2 2 year old
3 3 year old
4 4 year old
5 5 year old
6 6 year old
7 7 year old
8 8 year old
9 9 year old
10 10 year old
11 11 year old
12 12 year old
13 13 year old CONFIRM YOUNGEST CHILD, THEN SKIP TO Q12,
14 14 year old CONFIRM YOUNGEST CHILD, THEN SKIP TO Q12,
15 15 year old CONFIRM YOUNGEST CHILD, THEN SKIP TO Q12,
Q9b Is the (AGE) a boy or a girl?
1 Boy
2 Girl
Q9c How is the (AGE) related to you?
1 Child/stepchild
2 Grandchild
3 Sibling (brother/sister)
4 Other relative
5 Not related
ALL RESPONDENTS WHO HAVE SONS/DAUGHTERS UNDER AGE 13 GO TO Q16
IF CHILDREN IN HOUSEHOLD UNDER 13 BUT NONE ARE SONS/DAUGHTERS GO TO Q10
Q10 Do you ever drive with (the child/ at least one of the children under age 13) that you just mentioned?
1 Yes, one child in household SKIP TO Q16
2 Yes, more than one child
3 No SKIP TO Q12
8 Don't know SKIP TO Q12
Q11 Which of the children under age 13 do you ever drive with? ENTER AGE OF EACH CHILD BELOW.
_____ Age of child #1
_____ Age of child #2
_____ Age of child #3
_____ Age of child #4
_____ Age of child #5
_____ Age of child #6
ALL WHO ANSWERED Q11 GO TO Q16
Q12 In the past 12 months, have you driven with any children under age 13?
1 Yes
2 No SKIP TO Q89
8 Don't know SKIP TO Q89
Q13 How often do you drive with children under age 13? Is it........?
1 Almost every day
2 Few days a week
3 Few days a month
4 Few days a year
10 Never SKIP TO Q89
11 Other (SPECIFY)
98 Don’t know
Q14a What is your relationship to the child or children under age 13 that you at least sometimes drive with?
1 Child/stepchild
2 Brother/sister
3 Grandchild
4 Other relative
5 Non‑relative
8 Don’t know
IF CHILD/STEPCHILD IN Q14a, ANSWER Q14b and Q14c FOR EACH CHILD/STEPCHILD.
IF NO CHILD/STEPCHILD, SKIP TO Q15
Q14b What is the age of the youngest child under age 13?
_____ Years old (RANGE=0-12)
9 Age 13 or older
98 Don’t know
Q14c Is the child/stepchild a boy or a girl?
2 Girl
8 Don’t know
IF CHILD/STEPCHILD IN Q14a, SKIP TO Q16
Q15 When you are driving and children under age 13 are riding with you, would you say that they are in a car seat, booster seat, or a seat belt all of the time, most of the time, some of the time, rarely or never?
1 All of the time SKIP TO Q89
2 Most of the time SKIP TO Q89
3 Some of the time SKIP TO Q89
4 Rarely SKIP TO Q89
5 Never SKIP TO Q89
6 Depends on child SKIP TO Q89
8 Don’t know SKIP TO Q89
[FOR CHILD RESTRAINT MODULE, IMPLEMENT RANDOM CHILD SELECTION PROCEDURES TO SELECT REFERENT CHILD]
Q16 The following questions are for the (AGE), only. How much does the (AGE) weigh?
_____ Pounds SKIP TO Q17
If not sure, please provide your best estimate.
1 Less than 20 pounds
2 20 to 29 pounds
3 30 to 39 pounds
4 40 to 49 pounds
5 50 to 59 pounds
6 60 to 69 pounds
7 70 to 79 pounds
8 80 to 89 pounds
9 90 to 99 pounds
10 100 to 124 pounds
11 125 to 149 pounds
12 150 pounds or more
Q17 How did you determine the (AGE)’s weight when you answered the previous question?
1 Used the weight from the child’s last doctor’s visit;
2 Weighed the child yourself;
3 Guessed the child’s weight;
4 Determined the weight some other way (SPECIFY ______)
5 Don’t Know
Q18 How tall is the (AGE)? RECORD BOTH FEET AND INCHES.
_____ feet _____ inches
Q19 How did you determine the (AGE)’s height when you answered the previous question?
1 Used the height from the child’s last doctor’s visit;
2 Measured the child yourself;
3 Guessed the child’s height; or
4 Determined the height some other way (SPECIFY ______)
5 Don’t Know
20 When you are driving and the (AGE) rides in the vehicle with you, how often does (he/she) ride in a car seat. Car seats include booster seats. Would you say (he/she) rides in a car seat........?
1 All of the time
2 Most of the time
3 Some of the time
4 Rarely, or
5 Never SKIP TO Q76
6 Never drive with child SKIP TO Q89
8 Don't know
Q21 When was the last time the (AGE) DID NOT ride in a car seat when you were driving? (Remember, car seats include booster seats).
1 Today SKIP TO Q22
2 Within the past week SKIP TO Q22
3 Within the past month SKIP TO Q22
4 Within the past 12 months SKIP TO Q22
5 A year or more ago/ always wears it SKIP TO Q22
10 Never rides in car seat CONSISTENCY CHECK WITH Q20
11 Never drives with child in car CONSISTENCY CHECK WITH Q20
98 Don't know
Q21a Has there been any occasion in the past 12 months when the (AGE) did not ride in a car seat when you were driving?
1 Yes
2 No
8 Don’t know
Q22 When the (AGE) rides in the car seat, does the child wear harness straps that go over the shoulders and buckle between the legs?
1 Yes
2 No SKIP TO Q24
3 Never uses car seat CONSISTENCY CHECK WITH Q20
8 Don’t know SKIP TO Q25
Q23 Is the (AGE) usually in a front facing position when riding in the car seat, where the child faces towards the front of the vehicle? Or is the child usually in a rear facing position when riding in the car seat, where the child faces towards the rear of the vehicle?
1 Front facing SKIP TO Q25
2 Rear facing SKIP TO Q25
8 Don’t know SKIP TO Q25
Q24 Does the (AGE) ride in a booster seat?
1 Yes
2 No
8 Don’t know
Q25 Could you tell me the name and brand of car seat or booster seat the [Age] usually rides in?
(SPECIFY)
Q26 When you are driving with the (AGE) as a passenger, does the vehicle you usually drive have….?
1 A Front Seat only; SKIP TO Q28
2 Both a Front Seat and a Back Seat; or
3 A Front Seat and Multiple Rows of Back Seats
Q27 When you are driving and the (AGE) rides in the car seat, is he/she usually in the front seat or the back seat?
1 Front seat SKIP TO Q28
2 Back seat
8 Don't know SKIP TO Q28
Q27a Is the car seat usually behind the driver, behind the passenger or in the middle of the back seat?
1 Behind the driver
2 Behind the passenger
3 In the middle
8 Don't know
Q28 How many days out of the past thirty days did the (AGE) ride in a vehicle that you drove?
_____ Days (RANGE=0-30) Don’t know=98
Q29 During the past thirty days, has the (AGE) ridden in a vehicle where someone outside of your household was driving (includes school buses, taxis and other private vehicles)?
1 Yes
2 No SKIP TO Q30
8 Don’t know SKIP TO Q30
Q29a How many days out of the past thirty days did the (AGE) ride in a vehicle driven by someone outside of your household?
_____ Days (RANGE=0-30) Don’t know=98
Q29b Who were those drivers? (What is their relationship to the child?) CHECK ALL THAT APPLY.
1 Parent/step-parent
2 Brother/sister
3 Grandparent
4 Other relative
5 Daycare/childcare provider
6 Babysitter
7 Parent of friends
8 Bus driver
9 Other non‑relative
98 Don't know
Q30 Where would you say it is safest to place a car seat in the vehicle: in the front seat or in the back seat?
1 Front seat
2 Backseat
3 Depends on type of car seat
8 Don't know
Q31 Now thinking again about the car seat the (AGE) usually rides in, did you get the car seat new or used? Remember, car seats include booster seats.
1 New
2 Used
8 Don't know
Q32 How did you get the car seat the (AGE) is using? Did you:……?
Purchase it in a store
Purchase it online
Purchase it from an individual
Receive it as a gift from someone you know
Receive it as a loan from someone you know
Receive it free from an organization
Receive it as a loan from an organization
9 Other (SPECIFY)
98 Don't know
IF Q31=NEW OR DK, GO TO Q33, ELSE GO TO Q36
Q33 Was there a registration card that came with the car seat when you got it?
Yes
2 No
8 Don't know
Q34 Was there an online address that came with the car seat when you got it where you could register the car seat?
1 Yes
2 No
8 Don't know
IF NO IN BOTH Q33 AND Q34, SKIP TO Q36
Q35 Did you register the car seat, either by filling out and mailing the registration card or registering online?
Yes, sent back registration card
Yes, registered online
3 No
8 Don't know
Q36 When car seats are registered, it provides contact information that can be used to alert parents about a recall or safety issue related to the car seat. But even when registration cards or online addresses are provided, many parents do not register their car seats. What, if anything, do you think would get parents to register their car seats?
(Specify)
7 Don’t think anything would be effective
8 Don’t Know
Q37 Does the car seat have an expiration date or date of manufacture printed on it?
Yes, an expiration date
Yes, a date of manufacture
3 No
8 Don't know
Q38 Did you ever read or hear of any information or receive any advice about the need to use car seats from any of the following sources? Did you get any information........?
|
|
Yes |
No |
Don’t Know |
|
a. |
From a doctor or nurse |
1 |
2 |
8 |
|
b. |
From a book, magazine, or article |
1 |
2 |
8 |
|
c. |
From a daycare provider |
1 |
2 |
8 |
|
d. |
From TV or radio |
1 |
2 |
8 |
|
e. |
From a family member or friend |
1 |
2 |
8 |
|
f. |
From a safety hotline |
1 |
2 |
8 |
|
g. |
From the Internet |
1 |
2 |
8 |
|
h. |
From police or law enforcement agencies |
1 |
2 |
8 |
|
i. |
From anywhere else (Specify ) |
1 |
2 |
8 |
|
Q39 Have you seen or heard the following message within the past X months (Placeholder for NHTSA campaign message current at time of survey)?
1 Yes
2 No
8 Don't know
IF Q24=1 SKIP TO Q41
Q40 How did you learn to attach the car seat to the vehicle? CHECK ALL THAT APPLY.
1 Read the instructions
2 Relative or friend showed me
3 Went to fitting station/inspection station
4 Health professional showed me
5 Figured it out myself
6 Car seat came attached to car SKIP TO Q53
7 Saw on a TV program
8 Saw on-line
9 Police department showed me
10 Fire department showed me
11 Automobile dealership showed me
12 Pre-natal class showed me
13 Saw a video
14 Other (SPECIFY)
98 Don't know
IF YES IN Q40 #13, GO TO Q40a, ELSE SKIP TO Q41:
Q40a Can you tell me who sponsored the video?
1 Yes (Specify )
2 No
8 Don't know
IF Q40=1 THEN SKIP TO Q42 , ELSE GO TO Q41
Q41 Did you ever read the instructions for the car seat?
1 Yes
2 No SKIP TO Q44
8 Don't know SKIP TO Q44
Q42 Which instructions did you read or watch? Did you read or watch........? RANDOMIZE ORDER.
|
|
Yes |
No |
Don’t Know |
|
a. |
The instructions that were on the box for the car seat |
1 |
2 |
8 |
|
b. |
The instructions that were on the label of the car seat |
1 |
2 |
8 |
|
c. |
The car seat owner’s manual that came in the box with the car seat |
1 |
2 |
8 |
|
d. |
Instructions for the car seat that were available on-line |
1 |
2 |
8 |
|
e. |
A video that provided instructions for the car seat |
1 |
2 |
8 |
|
f. |
Instructions for the car seat in the owner’s manual for the automobile |
1 |
2 |
8 |
|
Q43 How easy or difficult were the instructions to understand? Would you say that the instructions were very easy, somewhat easy, somewhat difficult, or very difficult to understand?
1 Very easy SKIP TO Q45
2 Somewhat easy SKIP TO Q45
3 Somewhat difficult SKIP TO Q45
4 Very difficult SKIP TO Q45
8 Don’t know SKIP TO Q45
Q44 Were any instructions available?
1 Yes
2 No
8 Don't know
IF Q24=1 SKIP TO Q53
Q45 How easy or difficult is it for you to attach the car seat to the vehicle you usually drive?
1 Very easy SKIP TO Q47
2 Somewhat easy
3 Somewhat difficult, or
3 Very difficult
8 Don’t know SKIP TO Q47
Q46 What is difficult about attaching the car seat to the vehicle? CHECK ALL THAT APPLY.
1 Fitting the seatbelt through the car seat hole/loop
2 Hooking it/attaching to seat/buckle
3 Adjusting seatbelt making sure it is tight enough
4 Not enough room to maneuver/Design of backseat makes it awkward
5 I have to put my hand/arm through back of car seat to attach
6 Other (SPECIFY)
8 Don't know
Q47 When you attach the car seat to your (car/truck/van/SUV), what do you use to attach it?
(Specify )
8 Don’t know
Q48 Have you ever driven with the child in the car seat and later found that the car seat was not securely attached?
1 Yes
2 No SKIP TO Q49
8 Not sure SKIP TO Q49
Q48a Why did this happen? CHECK ALL THAT APPLY.
1 Forgot/wasn't paying attention
2 Hard to attach tightly enough
3 Seat put in by spouse/someone else who did not attach it right
4 Moved car seat between cars/within same car
5 Child knows how to unbuckle him/herself
6 Other child loosened baby's seat accidentally
7 Other (SPECIFY)
8 Don't know
Q49 When you attach the car seat to your vehicle, how confident do you usually feel that the car seat is correctly attached?
1 Very confident
2 Somewhat confident
3 Not confident
8 Don’t know
IF Q23=1 OR Q23=8 GO TO Q50, ELSE SKIP TO Q53
Q50 Some car seats have a strap on the BACK of the car seat, near the top. This strap or tether is designed to attach to a motor vehicle at a place behind the car seat when the child is sitting facing forward. Does the car seat you use with the (AGE) have this kind of tether strap on its back?
1 Yes
2 No SKIP TO Q53
8 Don't know SKIP TO Q53
Q51 When the (AGE) rides in the car seat, how often is the tether strap attached to the motor vehicle? Would you say that the tether strap is attached to the motor vehicle on all trips that the child rides in the car seat, most trips, some trips, or no trips?
1 All trips SKIP TO Q53
2 Most trips
3 Some trips
4 No trips
8 Don’t know
Q52 When the child is riding in the car seat and the tether strap is not attached to the motor vehicle, what are the reasons the tether strap is not attached? CHECK ALL THAT APPLY.
1 No place on vehicle to attach strap
2 Don’t know how to attach strap
3 Not required/needed
4 Didn’t want the hassle
5 Seatbelt is good enough
6 Forgot
8 Other (SPECIFY)
98 Don’t know
Q53 How easy or difficult is it for you to properly buckle your child into the car seat?
1 Very easy SKIP TO Q55
2 Somewhat easy
3. Somewhat difficult, or
4 Very difficult
5 Child buckles him/herself in SKIP TO Q55
8 Don't know SKIP TO Q55
Q54 What is difficult about buckling your child into the car seat? CHEC K ALL THAT APPLY.
1 Hard to snap/buckle
2 Adjusting shoulder straps to fit properly/tightness of seat
3 Heavy/bulky/winter clothing makes it difficult to buckle child
4 Child doesn't sit still/down/uncooperative/squirms
5 Difficult for adult to crawl/squeeze into rear of vehicle to buckle
6 Other (SPECIFY)
8 Don't know
Q55 Has the (AGE) ever gotten himself/herself out of the car seat while you were driving?
Yes
2 No
8 Don't know
Q56 How often do you move the car seat from one motor vehicle to another 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
10 Never
11 Other (SPECIFY)
98 Don't know
Q57 In many communities, there are places where people can go to have someone check whether they are correctly attaching their car seat and buckling in their children. Did you ever go to a place like this to have someone check how you were attaching a car seat?
Yes
No SKIP TO Q67
8 Don't know SKIP TO Q67
Q58 Could you tell me what type of organization or company sponsored the car seat check you went to? If you have gone to a car seat check more than once, please base your answers to the following questions on the last time you went. CHECK ALL THAT APPLY.
1 Car dealership
3 State or county
4 Police
5 Fire or rescue units
6 Retail store
7 Hospital/medical/health center
8 Charitable org/community service org/AAA/public interest
10 Other (SPECIFY)
98 Don't know
Q59 How did you find out about the car seat check you went to? CHECK ALL THAT APPLY.
1 Heard about it on television
2 Heard about it on radio
3 Read about it in a local paper
4 Someone I knew told me about it
5 Website/Internet
9 Flyers
10 Saw it taking place/Drove by
11 At work
12 Sign on the road/outside
13 Doctor’s office/Hospital
6 Other (SPECIFY)
98 Don’t know
Q60 Did the person who was checking the car seat for you find anything that was wrong in how you attached the seat or buckled in your child?
1 Yes
2 No
8 Don't know
Q61 Did the person who was checking the car seat for you suggest that you do anything differently in how you attach the seat or buckle in your child?
1 Yes
2 No SKIP TO Q62
8 Don't know SKIP TO Q62
Q61a What did that person suggest you do differently? CHECK ALL THAT APPLY.
1 Make seat belt tighter/More pressure on seat belt
2 Put knee/weight on car seat to fasten down more securely
3 Use foam/towel/something behind/underneath to make more secure
4 Adjust straps for the child
5 Other (SPECIFY)
8 Don’t know
Q62 Did the person who was checking the car seat for you suggest that you get a different car seat?
1 Yes
2 No
8 Don't know
Q63 During the car seat check, were you given a chance to practice attaching the seat and buckling in your child? Or did you spend all of the time watching someone else check the seat and show you how to attach it?
1 Given a chance to practice
2 Spent all of the time watching SKIP TO Q65
3 Other (SPECIFY)
8 Don’t know
Q64 Before leaving the car seat check, who was the last person to adjust the car seat?
1 You (respondent)
2 The person who checked the seat
3 Someone else (SPECIFY)
8 Don’t know
Q65 Which of the following statements best describes how you felt when you left the car seat
check?
1 You felt that you had not learned anything you did not already know;
2 You felt you had learned to do a better job installing the seat, but were still unsure you could do everything correctly; or
3 You felt fully confident that you could install the car seat correctly. SKIP TO Q67
8 Don’t know SKIP TO Q67
Q66 When you left, what did you feel most unsure about?
_________ (SPECIFY)
Don’t know=8
Q67 Car seats that are not booster seats are now designed to fasten into two sets of small bars, called lower anchors, located in the back seat of the vehicle where the upper and lower cushions meet. Does the vehicle you normally drive with the child have lower anchors?
1 Yes
2 No SKIP TO INSTRUCTION PRECEDING Q70
8 Don't know SKIP TO INSTRUCTION PRECEDING Q70
Q68 When you are driving with the (AGE), and the child is riding in a car seat, how often is the car seat attached to the lower anchors? Is the car seat attached to the lower anchors on…..?
1 All trips
2 Most trips
3 Some trips
4 Almost no trips
5 No trips
8 Don't know
Q69 Have you had any difficulties fastening the car seat into the lower anchors?
1 Yes
2 No
8 Don't know
IF [Q20= 1 (ALL THE TIME) AND {(Q21=5 (YR AGO/ALWAYS) OR Q21a=2 (NO)}] SKIP TO Q81 ELSE ASK Q70
The next questions will go back to discussing your (AGE) who uses a car seat. Again, car seats include booster seats.
Q70 Please answer yes or no to each of the following statements. When my (AGE) doesn't ride in a car seat, it is sometimes because...
|
|
Yes |
No |
Don’t Know |
|
a. |
He/she is too big |
1 |
2 |
8 |
|
b. |
He/she doesn’t like it |
1 |
2 |
8 |
|
c. |
He/she won’t stay in it |
1 |
2 |
8 |
|
d. |
There is no room for the seat in the car |
1 |
2 |
8 |
|
e. |
He/she will only be in the car a short time |
|
|
|
|
f. |
We are in a hurry |
|
|
|
|
g. |
The car seat isn’t available |
1 |
2 |
8 |
|
Q70h Are there any other reasons why (he/she) doesn't ride in a car seat?
1 Yes
2 No SKIP TO Q71
8 Don't know SKIP TO Q71
What other reasons? (Child doesn't ride in a car seat)
________ (SPECIFY)
Q71 When the (AGE) doesn't ride in the car seat when riding with you, does (he/she) usually sit in the front seat or in the back seat?
1 Front seat
2 Backseat
3 Other (Specify)
8 Don’t know
Q72 When the (AGE) doesn't ride in the car seat when riding with you, how often is (he/she) buckled in a seat belt?
1 All of the time
2 Most of the time
3 Some of the time
4 Rarely or
5 Never SKIP TO Q75
8 Not sure SKIP TO Q75
Q73 Does the seat belt that the child usually wears go across both the shoulder and lap, or just the lap?
1 Across shoulder and lap
2 Across lap only
8 Don't know
Q74 Please answer, yes or no, if the following things usually happen when the (AGE) wears a seat belt while riding in a motor vehicle. On most trips, does.....................?
|
Yes |
No |
Don’t Know |
|
|
1 |
2 |
8 |
|
|
1 |
2 |
8 |
|
|
1 |
2 |
8 |
|
|
1 |
2 |
8 |
|
|
1 |
2 |
8 |
|
|
1 |
2 |
8 |
|
Q75 In general, at what age do you think a child is ready to begin wearing only a seat belt rather than use some type of car seat? Again, car seats include booster seats.
BEGINNING AGE FOR SEAT BELT USE.
DON’T KNOW=98
IF Q20=5 (NEVER) OR q21=10 (NEVER) OR Q22=3 (NEVER) THEN CONTINUE WITH Q76, ELSE GO TO Q82
Q76 Please answer yes or no to each of the following statements to indicate if this is a reason why the (AGE) does not ride in a car seat. Again, car seats include booster seats.
My (AGE) doesn’t ride in a car seat because:
RANDOMIZE ORDER |
Yes |
No |
Don’t Know |
|
a. HE/SHE DOESN'T HAVE ONE |
1 |
2 |
8 |
|
b. HE/SHE IS TOO BIG |
1 |
2 |
8 |
|
c. HE/SHE DOESN'T LIKE IT |
1 |
2 |
8 |
|
d. HE/SHE WON'T STAY IN IT |
1 |
2 |
8 |
|
e. HE/SHE USES A SEAT BELT |
1 |
2 |
8 |
|
f. THERE ISN’T ENOUGH ROOM IN THE CAR |
1 |
2 |
8 |
|
g. THE LAW DOESN’T REQUIRE IT FOR THE CHILD’S AGE AND SIZE |
1 |
2 |
8 |
|
h. HE/SHE IS TOO OLD |
1 |
2 |
8 |
|
Q76i. Are there any other reasons why he/she doesn't ride in a car seat ?
1 Yes
2 No
8 Don't know
IF YES, What other reasons? (Child doesn't ride in a car seat)
__________________________________________
IF Q76a=1, ANSWER Q76j, ELSE SKIP TO Q77
Q76j Is there any particular reason why you don't have one?
1 Yes
2 No SKIP TO Q77
3 Don't know SKIP TO Q77
Q76j1 What is that reason? CHECK ALL THAT APPLY.
1 Too old/old enough to use seat belt
2 Child over weight limit/weighs enough not to use one
3 Child is too tall/tall enough not to use one
5 Child uses seat belt (no mention of size, weight, etc.)
6 Not required by law to use one
7 Not necessary/don't need one
8 Too expensive
9 Other (SPECIFY ________)
98 Don't know
Q77 Where does the (AGE) usually sit in the vehicle when you are driving -- the front seat or the back seat?
Front seat
Back seat
About equal
Other (SPECIFY )
98 Not sure
Q78 How often does he/she use a seat belt?
1 All of the time
2 Most of the time
3 Some of the time
4 Rarely or
5 Never SKIP TO Q81
8 Don't know SKIP TO Q81
Q79 Does the seat belt that the (AGE) usually wears go across both the shoulder and lap, or just the lap?
1 Across shoulder and lap
2 Across lap only
8 Don't know
Q80 Please tell me, yes or no, if the following things usually happen when the (AGE) wears a seat belt while riding in a motor vehicle. On most trips, does.................?
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Yes |
No |
Don’t Know |
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1 |
2 |
8 |
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1 |
2 |
8 |
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1 |
2 |
8 |
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1 |
2 |
8 |
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1 |
2 |
8 |
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1 |
2 |
8 |
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Q81 In general, at what age do you think a child is ready to begin wearing only a seat belt rather than use some type of car seat?
________________ BEGINNING AGE FOR SEAT BELT USE
DON’T KNOW=98
If Q24 = 1 SKIP TO Q84
Q82 Before today, had you ever seen or heard of a seat made for children riding in motor vehicles called a booster seat?
Yes
No SKIP TO Q88
8 Don't know SKIP TO Q88
Q83 Have you ever used a booster seat when driving with your (child/children)?
1 Yes
2 No SKIP TO Q86
8 Don't know SKIP TO Q86
Q84 At what age did you begin using a booster seat for your (child/children) (If more than one child, answer for the child that used a booster seat most recently)?
_______ AGE AT FIRST USE OF BOOSTER SEAT
(RANGE=0 TO 12; LESS THAN 1 YR=0; DON’T KNOW=98)
Q85 About how much did the child weigh at the time you began using a booster seat?
WEIGHT AT FIRST USE OF BOOSTER SEAT
(DON’T KNOW=998)
Q86 What would you say is the MOST IMPORTANT reason for having a child use a booster seat?
2 To make the seat belt fit properly
4 To allow the child to see out of the window better
5 It’s the law
6 Don’t want a ticket
8 When child is too big for safety seat but too small for seat belt
10 Keeps child still
7 Other (SPECIFY: __________________)
98 Don't know
Q87 In deciding whether a child is ready to stop using a car seat and instead can ride in a seat belt only, what would you base that decision on?
1 Child’s Height What height?
2 Child’s Weight What weight?
3. Child’s Age What age?
4. The fit of the seat belt
5 Child’s Preference
6 Child’s Behavior
7. Other (SPECIFY )
8 Don’t Know
IF Q20=5 or 6 OR Q21=10 or 11 OR Q22 = 3, SKIP TO Q89
Q88 When your (AGE) outgrows his/her current car seat, what do you expect him/her to use when riding in a motor vehicle?
1 A different type of car seat
2 A seat belt only
3 Nothing, no car seat nor seat belt
8 Other (SPECIFY )
98 Don’t know
Q89 When police in your community see a child riding in a motor vehicle that is not in a car seat or using a seat belt, how often do you think the police will ticket the driver?
1 Almost never
2 Sometimes
3 Often
4 Almost always
98 Don’t know
Q90 What do you think the fine should be for violation of car seat laws?
$__________
0 No fine/receive warning instead
9988 Don’t know
Q91 What about when children outgrow a car seat, including booster seats? Do you agree or disagree that they should be required by law to wear seat belts when riding in a vehicle?
1 Agree
2 Depends on age
3 Disagree SKIP TO Q93
8 Don't know SKIP TO Q93
Q92 How old do you think children should be before they are not required by law to wear seat belts or do you think all children should be required to wear them?
__________ AGE RANGE=0‑21
0=SHOULD NOT BE REQUIRED AT ANY AGE
21=SHOULD BE REQUIRED AT ANY AGE
98= DON’T KNOW
The next section is about Emergency Medical Services or EMS. EMS includes all the people in your community who respond to medical emergencies. It includes ambulances, rescue squads and hospital emergency services.
Q94 In many communities, both law enforcement and fire department services are considered essential government services, meaning that an interruption in their service would endanger the community. In your opinion, should EMS also be considered an essential government service?
1 Yes
2 No
3 Don’t Know
Q95 Most communities pay all costs for their police and fire department services. Do you agree or disagree that communities should pay the full cost of providing EMS services to their community members?
1 Agree
2 Disagree
3 Don’t Know
Q96 Have you, personally, ever called 911 or another emergency number for help? Please include any type of emergency, not just those involving motor vehicle crashes.
1 Yes
2 No SKIP TO Q99
8 Don’t know SKIP TO Q99
Q97 How long ago did that occur (the last time)?
1 Today
2 Within past week
3 Within past month
4 Within past 12 months
5 A year or more ago
8 Don't know
Q98 Did you call for police, fire, an ambulance or something else? Again, please include any type of emergency, not just those involving motor vehicle crashes. CHECK ALL THAT APPLY
1 Police
2 Fire
3 Ambulance
4 Rescue squad
5 EMS
6 Poison control
9 Other (SPECIFY )
10 Whoever 911 thought was appropriate
98 Don’t know
Q99 If you used a cell phone to call 911 about an emergency in your community, can the 911 Call Center identify your LOCATION without you telling them?
1 Yes
2 No
8 Don’t know
Q100 If you called 911 for a medical emergency that someone else was having, would you expect 911 to give you instructions on how to provide care while you were waiting for the ambulance to arrive?
1 Yes
2 No
8 Don’t know
Q101 When 911 is called, the 911 operator asks the caller a series of questions to decide how to respond to the call. Suppose you called 911, and the 911 operator decided from your answers that your problem was not a true medical emergency. How acceptable would it be to you if 911 did not send an ambulance but instead transferred your call to a certified nurse to give you medical instructions?
Very acceptable
Somewhat acceptable
Neither acceptable nor unacceptable
Somewhat unacceptable
Very unacceptable
Don’t Know
Q102 Suppose you called 911 about a medical emergency and an ambulance was sent. Regardless of the type of medical emergency, how confident are you that the arriving ambulance or other emergency workers would know what to do?
1 Very confident
2 Somewhat confident
3 Not confident
8 Don't know
Q103 If Emergency Medical Technicians (EMTs) arrive at a site and find emergency medical care is not required, do you approve or disapprove of the EMTs being allowed to carry out the following non-emergency services at that site?
a. Provide non-emergency medical care such as treatment for a sprained ankle.
Approve Disapprove
b. Provide medical instructions
Approve Disapprove
c. Provide transportation to a clinic
Approve Disapprove
d. Provide transportation to a doctor’s office
Approve Disapprove
Q104 This section asks about your experience in situations where someone else was having a medical emergency. The medical emergency could be anything -- an accident such as a fall or car crash, a medical condition such as a heart attack or seizure, or an injury resulting from violence. How long ago was the last time you were at a location where someone else was having a medical emergency?
Number of years ago
Within past year
Never SKIP TO Q108
Q105 The last time you were at a location where someone else was having a medical emergency, what caused the medical emergency?
A fall
A motor vehicle crash
An explosion
An object falling on someone
A medical condition such as heart attack, seizure, or stroke
A violent act by someone
Other (specify )
Don’t Know
Q106 The last time you were at a location where someone else was having a medical emergency, were there other people there besides yourself and the person(s) having the medical emergency?
Yes
No
Don’t Know
Q107 During that last time when you were at a place where someone was having a medical emergency, what did you do? CHECK ALL THAT APPLY.
Called for help
Called 911
Provided comfort
Attempted to stop bleeding
Performed CPR
Assisted others who were performing medical care
Stayed out of the way so others could help
Helped to manage the scene (such as direct traffic or control entry)
Other (SPECIFY )
The next section asks about a disaster situation, and how people might respond.
Q108 Suppose you were in a public place, an explosion occurred, and you didn’t know the source of the explosion. You see at least several people injured, but you and several other people nearby are unhurt or have only scratches. During the first few minutes after the explosion, which if any of the following would you likely do? CHECK ALL THAT APPLY.
Leave the area because it may still be unsafe
Call family or friends to let them know you were unhurt
Text family or friends to let them know you were unhurt
Call 911
Check for information about the blast using mobile technology
Try to help the injured
Look for someone trained to handle this type of situation
Help to manage the scene (such as direct traffic or control entry)
None of these
Don’t Know
Q109 What concerns would you have in helping an injured person in the situation just described? CHECK ALL THAT APPLY.
Concern about not knowing how to help
Concern about causing further injury to the victims
Concern for personal safety
Concern about getting sick from seeing blood or severe injuries
Concern about getting involved
Concern about legal liability
Would have no concerns
Don’t Know
Q110 Good Samaritan laws offer legal protection to people who give reasonable assistance to those who are injured or ill. Would you want to know if your State has a Good Samaritan law before you helped someone that was injured?
Yes
No
Don’t Know
Q111 If you tried to call for help during a disaster situation, but found that the call system was overloaded and you couldn’t get through, what communication method would you go to next to reach someone for help?
Another cell network
A landline or payphone
The social network through:
Google plus
Other (specify)
Wi Fi available from a nearby source
An FRS (Family Radio Service) radio
Other type of radio (CB, ham, etc.)
Other (specify)
None
Don’t Know
Q112 Communities pay for 911 call services through fees or taxes collected from the public. Would you be willing, or unwilling, to pay more than you currently pay for 911 call services to locate callers faster?
1 Willing to pay more
2 Unwilling to pay more SKIP TO Q114
8 Don’t know SKIP TO Q114
Q113 How much more would you be willing to pay per year for 911 call services? Would you be willing to pay less than $5 more, $5-$9 more, $10-$20 more or over $20 more per year?
1 Less than $5 more
2 $5 - $9 more
3 $10 - $20 more
4 Over $20 more
8 Don’t know
Q114 Communities use other fees and taxes collected from the public to help pay for their EMS systems, which include ambulances, rescue squads, and hospital emergency services. Would you be willing or unwilling to pay more than you currently pay for your community’s EMS system to improve EMS equipment and training?
1 Willing to pay more
2 Unwilling to pay more SKIP TO Q116
8 Don’t know SKIP TO Q116
Q115 How much more would you be willing to pay per year for your community’s EMS system? Would you be willing to pay less than $5 more, $5-$9 more, $10-$20 more or over $20 more per year?
1 Less than $5 more
2 $5 - $10 more
3 $10 - $20 more
4 Over $20 more
8 Don’t know
Q116 Assuming it was reasonably priced and in a convenient location, how interested would you be in taking training to become an emergency medical services provider?
1 Very interested
2 Somewhat interested
3 Not interested
4 Already have EMS training
5 Depends
8 Don’t know
If Q1=10 or 11 SKIP TO Q127
Q117 When you drive a motor vehicle, do you usually have a cell phone or some other type of wireless phone in the vehicle with you?
1 Yes
2 No SKIP TO Q124
8 Don’t Know SKIP TO Q124
Q118 When you drive, how often would you say you keep the phone turned on so that you can receive calls? Would you say that you keep the phone turned on during........?
1 All trips
2 Most trips
3 About half your trips
4 Fewer than half your trips, or
5 Never SKIP TO Q120
8 Don’t Know
Q119 When you get a call on the phone while you are driving, how often do you answer the call?
Would you say you always, usually, seldom, or never answer a call while driving?
1 Always
2 Usually
3 Seldom
4 Never
8 Don’t Know
Q120 How often do you talk on the phone while you are driving? Would you say you talk on the phone while driving during .................?
1 All trips
2 Most trips
3 About half your trips
4 Fewer than half your trips, or
5 Never SKIP TO Q124
8 Don’t Know
Q121 When you are talking on the phone while driving, do you tend to hold the phone with your hand or do you tend to use the phone hands free?
1 Hold phone SKIP TO Q123
2 Use hands free
8 Don’t Know SKIP TO Q123
Q121a Do you always use the phone hands free when you are talking on the phone while driving, or do you sometimes hold the phone by hand when driving and talking on the phone?
1 Always use hands free
2 Sometimes hold phone
8 Don’t Know
Q122 When you are talking on the phone while driving, do you usually use an earpiece or headset to talk, do you usually use a speakerphone to talk, or do you usually use something else to talk?
1 Earpiece/headset
2 Speakerphone SKIP TO Q123
6 Just the phone SKIP TO Q123
3 Something else (SPECIFY) SKIP TO Q123
8 Don’t Know SKIP TO Q123
Q122a When do you usually put the (earpiece/headset) on? Do you usually put the (earpiece/headset) on before you start driving, do you put it on while you are driving, or do you usually put it on while temporarily stopped?
1 Before start driving
2 While driving
3 When temporarily stopped
8 Don’t Know
Q123 When you are driving and want to dial the phone, do you tend to dial the phone WHILE you are driving, do you tend to dial the phone while you are TEMPORARILY STOPPED, or do you tend to PULL OVER AND STOP the motor vehicle before dialing?
1 While driving
2 When temporarily stopped
3 Pull over and stop
4 Never dial
8 Don’t Know
Q124 Does your State have a law that makes it illegal to talk on a handheld cell phone while driving?
1 Yes
2 No
8 Don’t Know
Q125 Have you ever used a cell phone or other type of wireless phone to report an emergency while you were driving or riding in a motor vehicle?
1 Yes
2 No SKIP TO Q126
8 Don’t Know SKIP TO Q126
Q125a What kind of emergency did you call about? CHECK ALL THAT APPLY.
1 Car stranded on road/breakdown/disabled vehicle
2 Drunk driver
3 Car accident/collision/wreck/crash
5 Reckless/aggressive driver
6 Debris on the road
7 Animal hit/struck
8 Fire
10 Medical emergency
11 Criminal behavior
12 Vehicle fire
13 Other (Specify__________)
Q126 Suppose that you are driving, you see an accident happen and no one is there at the scene to help. What concerns might you have about stopping to help? CHECK ALL THAT APPLY.
1 No concerns
2 Lawsuits/liability
3 Not knowing what to do/how to help
4 Trick to get you to stop
5 Causing further injury to victim
6 Personal safety
7 Safety of my children/passengers
8 How injured the victim might be/seriousness of injury
14 Don’t want to see dead/mangled bodies
15 Not physically able to help/too old to help
13 Other (SPECIFY )
98 Don’t know
Q127 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 Q142
8 Don't know SKIP TO Q142
Q128 How many times have you been injured in a motor vehicle accident?
________ Number of times
98 = DON'T KNOW
Q129 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
Q130 In that accident, were you a …..?
1 Driver
2 Passenger
3 Pedestrian
4 Bicyclist
5 Motorcyclist
10 Other (SPECIFY )
98 Don’t know
IF Q130 = 3, 4, OR 5 SKIP TO Q132
Q131 Were you wearing your seat belt at the time of the accident?
1 Yes
2 No
8 Don't know
Q132 At which of the following were you treated for your injuries?
Were you treated at ...?
|
Yes |
No |
Not Sure |
|
|
1 |
2 |
8 |
|
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1 |
2 |
8 |
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1 |
2 |
8 |
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1 |
2 |
8 |
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1 |
2 |
8 |
|
Q133 Were you transported from the accident scene by ambulance or helicopter?
1 Yes, ambulance (or rescue vehicle)
2 Yes, helicopter
3 No, neither
8 Don't know
Q134 Were you hospitalized?
1 Yes
2 No SKIP TO Q136
8 Don't know SKIP TO Q136
Q135 How long were you hospitalized?
_____ Days _____ Hours Don’t know
Q136 Did you receive any continuing or follow-up treatment for your injuries?
1 Yes
2 No SKIP TO Q137
8 Don't know SKIP TO Q137
Q136a Where did you receive this follow-up treatment? Was it at...........?
|
Yes |
No |
Don’t Know |
|
|
1 |
2 |
8 |
|
|
1 |
2 |
8 |
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1 |
2 |
8 |
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1 |
2 |
8 |
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1 |
2 |
8 |
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1 |
2 |
8 |
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___________________
Q137 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 |
|
Q139 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 |
There are just a few more questions about yourself and then the survey will be done.
Q142 Are you a male or a female?
1 Male
2 Female
Q143 What is your age?
__________ AGE
Q144 Do you consider yourself to be Hispanic or Latino?
1 Yes
2 No
Q145 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
Q146 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
Q147 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 Not sure
That completes the survey. Thank you very much for your time and cooperation.
| File Type | application/msword |
| File Title | SCHULMAN, RONCA AND BUCUVALAS, INC |
| Author | alan.block |
| Last Modified By | alan.block |
| File Modified | 2015-02-23 |
| File Created | 2015-02-23 |