Form NHTSA Form 1010 NHTSA Form 1010 National Survey of the Use of Booster Seats

National Survey of the Use of Booster Seats Recording Form
Paperwork Reduction Act Burden Statement
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 2127-0644. 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, NHTSA, 1200 New
Jersey Avenue, SW, Washington, DC 20590.

My name is ____________ from
Westat, a national research
organization. We are
conducting a child travel survey
for the National Highway
Traffic Safety Administration.
We would like to ask a few
simple questions. No personal
identifying information will be
collected and only project staff
will be able to see your
responses.
NHTSA Form 1010

Booklet #

Date:
Booklet Start Time:

AM PM

Booklet End Time:

AM PM

PSU #:
Site Type:

OMB Control No. 2127-0644
Expiration Date xx/xx/xxxx

of

Site #:
Child Care

Rec Center

Fast Food

Gas Station

Site Name:
Street Address:
Weather:

Light Precipitation

Total Vehicles Observed:
Total Children Observed:
Total Children Interviewed:

Light Fog

Clear

Total Missed Interviews:
Total Refusals:
Total Language Barriers:
Total Unobserved Vehicles:

BARCODE
PLACEHOLDER

Observer Name: __________________

OMB Control No. 2127-0644
Expiration Date xx/xx/xxxx

Hi, My name is ____________ from
Westat, a national research
organization. We are conducting a
child travel survey for the National
Highway Traffic Safety
Administration. We would like to
ask a few simple questions. No
personal identifying information
will be collected and only project
staff will be able to see your
responses.

Notes:

NHTSA Form 1010

Tally of Unobserved Vehicles:

Circle Vehicle Information:

Page 1

1st Row
DriverD1
Y2

A3

MiddleM1

S4

1 LS

UB 6

1 M

C: 0 - 12

C 0 T 1 Y 2
A 3
S 4

1

RF

FF

3

2

RF

FF

4

HB

NB 5

4

HB

NB 5

6

1

M

F

1

A : 25 – 69
S: 70+

2. Restraint Use

3

6

UB
2

T: 13 - 15

Y: 16 - 24

1

LS

2

UB

F 2

RightR1

C 0 T 1 Y 2
A 3
S 4
LS

1. Age Group

M

3. Gender

2

F

Car1

/

Driver ONLY
What is your age?

‘/

LBS.
LBS.

1

Y

N

2

W

FT / IN

“

‘/

Y

1

W

1

2

1

Y
W

2

B

2

B

2

B

3

A

3

A

3

A

4

PI

4

PI

4

PI

5

NA

5

NA

5

NA

6 Other

6 Other

6 Other

7

RF

7

RF

7

RF

8

DK

8

DK

8

DK

NHTSA Form 1010

“

LBS.

1

N

4.
5.

2

RightR2

Driver SideD3

C 0 T 1 Y 2
A 3
S 4

C 0 T 1 Y 2
A 3
S 4

C 0 T 1 Y 2
A 3
S 4

C 0 T 1 Y 2
A 3
S 4

8. What is your Race?

(up to 3)
• White (W)
• Black or African
American (B)
• Asian (A)
• Native Hawaiian or
Pacific Islander (PI)
• American Indian or
Alaskan Native (NA)
• Other
• Refuse Answer
• Don’t Know

1

LS

1

LS

C 0 T 1 Y 2 C 0 T 1 Y 2
A 3
S 4
A 3
S 4

1

LS

RightR3

MiddleM3

1

LS

1

LS

2

RF

FF

3

2

RF

FF

3

2

RF

FF

3

2

RF

FF

3

2

RF

FF

3

2

RF

FF

4

HB

NB 5

4

HB

NB 5

4

HB

NB 5

4

HB

NB 5

4

HB

NB 5

4

HB

NB 5

1

6
UB
M
F 2

6

UB
1

M

2

F

1

FT / IN

FT / IN

FT / IN

/

‘/

LBS.

2
2
3
3
4
4
5
5
6
6
7
7
8
8

Y
W
W
B
B
A
A
PI
PI
NA
NA
Other
Other
RF
RF
DK
DK

N

M

2

F

1

M

“

‘/

1

Y

1

YY / MM

Y

FT / IN

“

‘/

Y

W

1

2

B

3

W

1

2

B

A

3

4

PI

5

NA

6 Other

FT / IN

“

‘/

Y

W

1

2

B

A

3

4

PI

5

NA

6 Other

2

2

F

YY / MM

/

FT / IN

“

‘/

LBS.

1

N

M

/

LBS.

1

2

1

YY / MM

/

LBS.

1

N

6

UB
2

F

3

Missed Interview3

/

LBS.

2

1

6

UB

Language Barrier2
YY / MM

“

UB6
2

F

YY / MM

‘/

1
1

M

YY / MM

/

1

6

UB

INTERVIEWS

What is Child’s Height?

7. Are you of Hispanic
or Latino origin?

1

LS

What is Child’s Age?

All Occupants

3rd Row

MiddleM2

6. What is Child’s Weight?

N

OMB Control No. 2127-0644
Expiration Date xx/xx/xxxx

SUV4

Driver SideD2

Children ONLY(< 12 yrs)

/

FT / IN

YY

1

YY / MM

Pickup3

OBSERVATIONS
2nd Row

Refused Entire Interview1
YY / MM

Minivan2

LBS.

1

Y

W

1

W

2

B

2

B

A

3

A

3

A

4

PI

4

PI

4

PI

5

NA

5

NA

5

NA

6 Other

N

2

6 Other

“

N

2

6 Other

7

RF

7

RF

7

RF

7

RF

7

RF

8

DK

8

DK

8

DK

8

DK

8

DK

N

2