Form 1325 Seat Belt Survey

OMB Control No. 2127-XXXX

Expiration Date XX/XX/XXXX

Appendix C

Seat Belt Survey

Form 1325

Several Driver Licensing Offices are participating in a study about community-oriented law enforcement. Your answers to the following questions are voluntary and anonymous. Please complete the survey and drop it in the box before you leave.

This collection of information is voluntary and will be used for statistical purposes only so that we may develop and evaluate programs designed to reduce the number of traffic-related injuries and deaths. The public reporting burden is estimated to average 10 minutes 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. Your 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.

1. Your sex: [] Male [] Female

2. Your age: [] Under 18 [] 18-20 [] 21-34 [] 35-49 [] 50-59 [] 60 Plus

3. What is your zip code? __ __ __ __ __

4. Do you consider yourself Hispanic or Latino? [] Yes [] No

5. Your race: Check all that apply: [] White [] Black or African American [] American Indian or Alaska Native [] Asian [] Native Hawaiian or other Pacific Islander

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

[] Less than HS

[] HS or equivalent

[] Some college but no degree

[] College graduate and beyond

7. How often do you typically drive a car or other motor vehicle?

[] Everyday [] Several Days a Week [] Once a Week or Less [] Only Certain Times a Year [] Never

8. What type of vehicle do you drive most often?

[] Passenger car [] Pickup truck [] Sport utility vehicle [] Mini-van [] Full-van [] Other

9. How often do you wear a seat belt?

[] All of the Time [] Most of the Time [] Some of the Time [] Rarely [] Never

9a. If you answered all the time or most of the time, why do you wear it? (Select all that apply)

[] For my safety [] It’s the law [] I don’t want to get a ticket

[] Everyone else wears it [] My relatives and friends wear it

[] Other? ­___________________________________

10. When was the last time you did NOT wear a seat belt?

[] Within the past day [] Within the past week [] Within the past month [] Within the past year [] A year or more ago

11. In the past 30 days, has your use of seat belts increased, decreased, or stayed the same?

[] Increased [] Decreased [] Stayed the Same

12. If an increase, what caused your use of seat belts to increase?

[] Increased awareness of safety [] Don’t want to get a ticket [] Stayed the Same

[] Other? ­___________________________________

13. Assume that you do not use 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?

[] Very likely [] Somewhat likely [] Somewhat unlikely [] Very Unlikely

14. To what degree to you agree with the following statements?

14a. Police in my community generally will not bother to write tickets for seat belt violations.

[] Strongly Agree [] Somewhat Agree [] Somewhat Disagree [] Strongly Disagree

14b. Police in my community are writing more seat belt tickets now than they were a few months ago.

[] Strongly Agree [] Somewhat Agree [] Somewhat Disagree [] Strongly Disagree

15. In the past 30 days, have you seen or heard of any special effort by police to ticket drivers in your community for seat belt violations?

[] Yes [] No

16. Have you recently read, seen or heard any messages about seat belt programs happening in your community?

[] Yes [] No

If yes, where did you see or hear about it? (Select all that apply)

[] Newspaper [] Radio [] TV [] Billboards [] Brochure [] Online [] Police Enforcement [] Other

If yes, what did it say? ___________________________________________________________

17. Do you know the name of any seat belt programs happening in your community? (Select all that apply):

[] Click It or Ticket [] Community Program Slogan #1 [] Community Program Slogan #2

18. To what degree do you support seat belt enforcement as an important police activity in your community?

[] Strongly Support [] Somewhat Support [] Somewhat Don’t Support [] Don’t Support

19. In the past 12 months, have you been in contact with the local police from your community for any reason?

[] Yes [] No

20. How would you best describe your contact with the police? (Select all that apply)

[] Reported a crime to police

[] Traffic violation stop

[] Car crash

[] Casual conversation with a police officer

[] Officer responding to call for service

[] Participated in a survey given by the police department

[] Asked the police for information or advice

[] Participated in a community activity that involved the police (e.g., clean-up, social event, community meeting)

[] Working with police to address specific problems

[] Other? ___________________________________________________________

21. In the past 12 months, have you observed any increases or decreases in police officer presence in your community or did the police presence stay the same?

[] Increase [] Decrease [] No change [] Never see police in my community

22. In the past 12 months, what activities have you seen police doing? (Select all that apply)

[] Police talking with residents in the community/neighborhood/site

[] Police talking with business owners in the community/neighborhood/site

[] Police attending community meetings

[] Police facilitating traffic watch and seat belt enforcement activities

[] Police involved with kids through recreational or school activities (e.g., DARE)

[] Other activities you have noticed? ___________________________________________________________

23. In the past 12 months, have you heard about any community meetings concerning traffic safety and seat belts taking place in your community?

[] Yes [] No

24. In the past 12 months, have you attended any of these community meetings?

[] Yes [] No

25. What are your reasons for not attending any meetings? (Select all that apply)

[] Don’t have time to attend

[] Aware of meetings, but do not know location and/or dates/times

[] Unable to obtain transportation

[] Unable to obtain child care

[] Meetings held in unsafe/scary part of town

[] Attendance would not help the seat belt problem in my community

[] Meeting place is too far

[] Meetings take place during work hours

[] Not especially concerned about seat belt use in my community

[] Other? ___________________________________________________________

26. How much work are police doing with the residents of your community to increase seat belt use?

[] A lot [] Some [] Very Little [] Nothing at all

27. Are you familiar with community-oriented policing?

[] Yes [] No

28. Community-oriented policing involves police officers working in partnership with the community to address community concerns regarding seat belt use. Based upon this definition, do you think the police in your community practice community-oriented seat belt enforcement?

[] Yes [] No

29. Do you have any additional thoughts or comments regarding community-oriented seat belt enforcement programs taking place in your community?

NHTSA Form #1325