NHTSA Form 1488 PRG Screner for Recruiting

OMB Control No. 2127-0682

Expiration Date 08/21/2021

Recruitment Screener for Focus Groups

Focus Groups for Increasing Safety Belt Use Among Rural Populations

OMB Control No: 2127-0682

FACE-TO-FACE SCREENING INTERVIEW GUIDE

NOTE TO RECRUITER: Approach individuals who appear to be at least 18 years of age or older. Follow the bolded script below.

I. Hi. I work for Preusser Research Group/PRG. We are working with the United States Department of Transportation on a study focused on seat belt use. The goal of the study is to learn more about people’s attitudes, behaviors and knowledge regarding seat belt use. We will be collecting data for the study in the form of focus groups. These focus groups will be taking place in the next few days with (add name of county) residents. Snacks and drinks will be available for participants a maximum of 15 participants), Only the 15 participants to complete the 60 to 90- minute focus group session will receive a $25 gift certificate to ___________ (e.g. Walmart).

Are you over 18 and interested in participating in the focus group if you qualify?

( ) Yes. [Continue to Section II.]

( ) No. Ok. Thank you for your time. END

II. Ok. I need to ask a few qualifying questions but, before I get started, I need to make sure you understand that:

[NOTE TO SCREENER: READ ALOUD the following bulleted statements}

• This collection of information is voluntary and will be used for formative purposes only so that we may develop a communications program 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 2127-0682.

• Public reporting for this collection of information is estimated to be approximately 5 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

• All the information you provide will be kept confidential.

III. Focus group participants must meet a few requirements.

1. Again, I need to confirm that you are over the age of 18?

( ) Yes.

( ) No. [Ok. Thank you for your time.] END

2. Do you have a valid driver’s license?

( ) Yes.

( ) No. [Ok. Thank you for your time.] END

3. Do you live in _____________ County?

( ) Yes.

( ) No. [Ok. Thank you for your time.] END

4. Do you, or does anyone living in your household, work in law enforcement or as an elected official?

( ) Yes. [Ok. Thank you for your time.] END

( ) No.

[If answered ‘Yes’ to questions 1-3 and ‘No’ to question 4, continue to Section IV.]

IV. Ok. You qualify to participate in the focus group. We will have three focus group meetings over the next few days. Which meeting will you attend?

1) Tomorrow morning at (time and location) ;

2) Tomorrow afternoon at (time and location); or

3) Weekend morning/afternoon at (time and location).

Great! The maximum size of each group is 15. The first 15 to show up will get to participate and will receive the $25 gift card, so make sure to arrive a little early. Thank you!

Recruit No. _______________ Date: _______________ Time:_______________ Location:_______________

NHTSA Form 1488