NHTSA Form 1303 Recruitment Screener

OMB Control No. 2127-XXXX

Expiration Date XX/XX/XXXX

Appendix E

Recruitment Screener Guide

This collection of information is voluntary and will be used to determine eligibility to participate in the study. The results of the study will be used to develop programs designed to reduce the number of traffic-related injuries and deaths. 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-XXXX. Public reporting for this collection of information is estimated to be approximately 15 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.

Correct Child Resistance Seat Install Evaluation Study

Project Number: 6286.01

Date: ______________________

Thank you for your interest in our study. First, let me explain to you what the study will be about and if you are still interested, I will need to get some information from you.

Westat will be conducting the study for the Federal Government. The study will take about 2 hours and will take place at ______________ (fill in location). There is no special knowledge or ability required to participate. As part of the study, you will be asked to complete three brief questionnaires and you will be asked to install four child safety seats and secure child-sized dolls into different vehicles. You will be paid $75 for your participation.

We will not be scheduling you for the study today. We need to get a group of available people together before we try to schedule a session. If you are eligible, we will add your name to the list of potential participants.

If you are interested, I will need to ask you a few questions to determine your eligibility. Are you interested in participating?

a. Yes (If yes, complete rest of form starting at question 1).

b. No (If no, thank the person for their time and end the screener).

1. Name: _________________________

2. [From observation, enter sex of respondent.] If unsure ask: Would you please tell me your gender?

a. Male b. Female c. Other

3. How old are you? __________________________

[If under 18, thank the person for their time and end the screener]

4. Do you have a valid driver license?

a. Yes b. No

5. Are you or a spouse or partner currently pregnant?

a. Yes b. No

6. Do children under the age of 12 reside in your household?

a. Yes b. No

[If yes, go to question 7, if no skip to question 8]

7. How many children under the age of 12 reside in your household? What are their ages?

Number of Children: _______

Age of Child 1: _______ Age of Child 2: _______

Age of Child 3: _______ Age of Child 4: _______

8. Do you regularly transport a child age 4 or younger at least two times per week?

a. Yes b. No

[If yes, go to question 9, if no skip to question 12]

9. Do you use a child safety seat when you transport the child who is age 4 or younger?

a. Yes b. No

[If yes, go to question 10, if no skip to question 12]

10. What is the make/model of the child safety seat you use to transport the child age 4 or younger?

_____________________________________________________________________

[Note: The participant may say the make/model of the seat or they may say the seat type, such as infant carrier. Probe for make/model but if they cannot remember write down whatever is said]

11. In the past six months, how often have you used a child safety seat to secure the child passenger age 4 or younger during transport?

a. Once or twice

b. Three or four times

c. Five or Six times

d. Seven or more times

12. Do you regularly transport a child age 5 or older at least two times per week?

a. Yes b. No

[If yes, go to question 13, if no skip to question 15]

13. Do you use a child safety seat when you transport the child who is age 5 or older?

a. Yes b. No

[If yes, go to question 14, if no skip to question 15]

14. What make/model of the child safety seat you use when transporting the child who is age 5 or older?

_____________________________________________________________________

[Note: The participant may say the make/model of the seat or they may say the seat type, such as booster seat. Probe for make/model but if they cannot remember write down whatever is said]

15. Have you ever installed a child safety seat in a vehicle?

a. Yes b. No

[If yes, go to question 16, if no skip to question 20]

16. Which of the following types of child safety seats have you installed?

[Circle all that apply]

a. Infant carrier or rear facing only

b. Rear facing convertible

c. Forward facing convertible

d. High back booster seat

e. No back booster seat

17. In which of the following vehicle types have you installed a child safety seat?

[Circle all that apply]

a. 4-door sedan

b. 2-door sedan or coupe

c. Small SUV (i.e. Toyota RAV-4 or Honda CRV)

d. Large SUV (i.e. Toyota 4Runner or Honda Pilot)

e. Minivan

f. Pick-up Truck

18. How many times in the past year have you installed a child safety seat in a vehicle?

a. None

b. 1-to-2 times

c. 3-to-5 times

d. More than 6 times

[If “None,” skip to question 20]

19. In the past year, when installing a child safety seat in a vehicle, what method do you typically used?

[Circle all that apply]

a. Lower Anchors or the LATCH system

b. Top Tethers

c. The vehicles’ seat belt system

d. Other __________________

20. Have you ever attended a car seat check or been to a car seat inspection station, for example at the firehouse?

a. Yes b. No

[If yes, go to question 21, if no skip to question 23]

21. When was the last time you attended a car seat check or visited a car seat inspection station?

a. Within the past month

b. Not within the past month, but within the past 6 months

c. Not within the past 6 months, but less than a year ago

d. More than 1 year ago, but less than 2 years ago

e. More than 2 years ago, but less than 3 years ago

f. More than 3 years ago

22. Have you ever worked at a car seat check or inspection station?

a. Yes b. No

[If yes, place on the wait list]

23. What is your highest level of education completed?

a. Did Not Complete High School

b. High School/GED

c. Some College

d. Bachelor's Degree

e. Master's Degree

f. Advanced Graduate work or Ph.D.

g. Not Sure

24. Is English your native language?

a. Yes b. No

[If no, place unto a wait list]

25. As part of this study, we will be asking that you to climb in and out of vehicles, apply weight into car seats and manually adjust seat belts. You will need to lift items that weigh up to 25 pounds multiple times over the course of 3 hours. Do you have any physical limitations that may prevent you from completing these tasks?

a. Yes b. No

[If yes, thank them for their time and end the screener]

26. Do you have any medical conditions affecting dexterity or motor skills?

a. Yes b. No

27. Are you of Hispanic or Latino origin?

a. Yes b. No

28. Please indicate all that apply to you:

[Circle 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/Caucasian

29. What is the make and model of the vehicle that you currently drive?

Make: _____________________ Model: _______________________

30. Can you tell me a phone number where we can easily contact you?

Home: ______________________________________________________

Cell: ________________________________________________________

31. Email Address:

_____________________________________________________________

32. Home City and State:

______________________________________________________________

33. How did you hear about the study?

1. Newspaper

2. Friend

3. Email

4. Craig’s List

5. Flyer

6. MVA

7. Other ___________________________

34. Can you tell me which days and times of the week when you might be available, if you are selected to participate?

__________________________________________________________________

__________________________________________________________________

Closing:

Thank you for your time and interest. Once we get a pool of names together, we will schedule the study session. We cannot guarantee that you will be included, because it depends on the scheduled session times and the total number of people that recruited. However we will make every effort to include you.

Hang up phone.

NHTSA Form 1303 13