Form 1365 Survey Screener

OMB Control Number: 2017XX-2127-XXX

Expiration Date: XX/XX/XXXX

Psychological Constructs Related to Seat Belt Use

Survey Screener

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to 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 XXXX-XXXX (expiration date: MM/DD/YYYY). The average amount of time to complete this survey is 1 minute. All responses to this collection of information are voluntary. The purpose of this research is to identify psychological constructs and psychosocial factors associated with not wearing seat belts. This research will inform development of countermeasures designed to more effectively encourage seat belt use. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden send them to Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

Protecting your privacy is important. We use confidentiality standards set by the Council of American Survey Research Organizations. We never give your identity or contact information to anyone without your permission. You can read our Panel Member privacy statement here.

Screener

1. How often do you DRIVE a motor vehicle (car, van, truck, taxi or ridesharing service)?

2. How often do you RIDE AS A PASSENGER in a motor vehicle (car, van, truck, taxi or ridesharing service)?

2. When driving or riding as a passenger in a motor vehicle (car, van, truck, taxi or ridesharing service), how often do you wear your seat belt?

2. When was the last time you did NOT wear your seat belt when DRIVING a motor vehicle (car, van, truck, taxi or ridesharing service)?

2. When was the last time you did NOT wear your seat belt when RIDING AS A PASSENGER in a motor vehicle (car, van, truck, taxi or ridesharing service)?

NHTSA Form Number 1365