NIOSH Center for Motor Vehicle Safety Needs Assessment and Audience Analysis

Form Approved

OMB No.0920-0953

Expires XX/XX/XXXX

Small Business Focus Groups on

Work-Related Motor Vehicle Safety Communication Products

Demographic Survey

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Welcome!

Please tell us a bit about you by circling the correct response or responses from the options below. We will use this information to better understand your comments today in relation to the comments of others. Only the people conducting these focus groups will have access to your responses. None of the information collected will be attached to your name, shared with your employer, or reported on an individual basis. If you are uncomfortable providing a response, you may skip any question.

1. How long have you worked for your current employer?

1. Less than 1 year

2. 1-5 years

3. 6-10 years

4. More than 10 years

2. How long have you worked in your current position?

1. Less than 1 year

2. 1-5 years

3. 6-10 years

4. More than 10 years

Public reporting burden of this collection of information is estimated to average 2 hours 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. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0953).

3. What department or division do you work in?

1. Finance

2. Human Resources

3. Operations Management

4. Risk Management

5. Safety

6. Other, please specify

4. Do you manage employees or contractors who operate a motor vehicle for work?

1. Yes

2. No

5. During a typical work week, how many hours do you spend on duties related to employee safety?

_________ hours per week

6. During a typical work week, how many hours do you spend on duties related to motor vehicle safety?

_________ hours per week

7. How old are you?

1. Under 30 years of age

2. 30-39

3. 40-49

4. 50-59

5. 60 years or older

8. What is the highest level of education you have completed or the highest degree you have received?

1. Did not complete high school

2. High school graduate, diploma or GED/equivalent

3. Trade/technical/vocational training

4. Associate/Junior College degree

5. Bachelor’s degree

6. Graduate or professional school degree

9. I identify my gender as:

1. Female

2. Male

3. Transgender

Please answer BOTH Question 10 about Hispanic origin and Question 11 about race. For this survey, Hispanic origins are not races.

10. Are you of Hispanic, Latino, or Spanish origin?

1. No, not of Hispanic, Latino, or Spanish origin

2. Yes, Mexican, Mexican American, or Chicano

3. Yes, Puerto Rican

4. Yes, Cuban

5. Yes, another Hispanic, Latino, or Spanish origin

11. What is your race? Choose all that apply.

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

6. Some other race. Please specify: ________________________

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