Form 1321 Survey Screener

OMB Control No. 2127-XXXX

Expiration Date XX/XX/XXXX

Appendix A

Survey Screener

Form 1321

Survey Screener

Hello, I'm __________________ distributing surveys for the U.S. Department of Transportation. Several Driver Licensing Offices are participating in a study about community-oriented enforcement. We are looking for drivers 18 years and over to complete a 10 minute survey. Participation is voluntary and anonymous.

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.)

Are you a licensed driver?

1. Yes

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

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 service. Would you mind completing the survey and dropping it in the box over there [indicate where to drop surveys] before you leave? [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 XXXX-XXXX.

Please select one of the following disposition codes

 I – Ineligable

 R – Refusal

 O – Other

Specify:______________________________________________

NHTSA Form #1321