Form 1495 Highway Safety Questionnaire

Completion time: 25 minutes OMB Control Number: 2127-NEW

Expiration Date: XX/XX/XXXX

Questionnaire Introduction

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 2127-NEW (expiration date: MM/DD/YYYY). The average amount of time to complete the survey is 25 minutes. All responses to this collection of information are voluntary. 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.

Thank you for completing this questionnaire.

We ask that you try to provide honest and thoughtful responses to these questions to help us gain a better understanding of driver behavior. Please note that your answers will be kept STRICTLY CONFIDENTIAL and PRIVATE and they will not be associated with any personal or identifying information.

Section A

In the last 30 days, how often did you:
		Never	Rarely	Sometimes	Often	All the time
A1	Run red lights					
A2	Take risks while driving because it’s fun					
A3	Change lanes suddenly to get ahead in traffic					
A4	Go through a stop sign without stopping					
A5	Speed for the thrill of it					
A6	Not yield the right of way					
A7	Make illegal turns					
A8	Follow a car very closely or “tailgate”					
A9	Follow emergency vehicles when the siren was on					
A10	Take more risks because you were in a hurry					
A11	Drive at your normal speed during bad weather (e.g., heavy rain, ice, or snow)					
A12	Use the right lane to pass another car					
A13	Try to be the first off the line when a light turns green					
A14	Accelerate when a traffic light turns yellow					
A15	Cut off, honk or yell at other drivers who drive too slowly or cut you off					

		Never	Rarely	Sometimes	Often	All the time
A16	Race other cars					
A17	Not check the rearview mirror when passing another car or merging onto the highway					
A18	Drive 10-20 mph over the speed limit					
A19	Drive more than 20 mph over the speed limit					
A20	Not yield to pedestrians					
A21	Pass where visibility was obscured					
A22	Use the shoulder of the road to pass another car					
A23	Speed in construction zones					

A24	Which of the following statements best describes your driving? Please select one response.		I tend to pass other cars more often than other cars pass me Other cars tend to pass me more often then I pass them Both/About equally Don’t Know Prefer not to answer
A25	When driving I tend to…		Stay with slower moving traffic Keep up with the faster traffic Both/About equally Don’t Know Prefer not to answer

This section concerns how people may change the way they drive on different types of roads, such as multi-lane highways, rural routes, or residential streets.
		Never	Rarely	Sometimes	Often	Don’t Know
A26	How often would you say you drive 15 miles an hour over the speed limit on multi-lane divided highways?					
A27	How often would you say you drive 15 miles an hour over the speed limit on multi-lane, interstate freeways through major towns or cities?					
A28	How often would you say you drive 15 miles an hour over the speed limit on two-lane highways, one lane in each direction in rural areas?					
A29	How often would you say you drive 10 miles an hour over the speed limit on rural country roads?					
A30	How often would you say you drive 10 miles an hour over the speed limit on neighborhood or residential streets?					
A31	How often would you say you drive 10 miles an hour over the speed limit on main roads in town that have two lanes in each direction?					

Section B

Indicate how much you agree or disagree that driving within or near the speed limit…
		Disagree	Somewhat Disagree	Neither	Somewhat Agree	Agree
B1	Puts pedestrians at less risk					
B2	Reduces my chances of an accident					
B3	Makes it difficult to keep up with traffic					
B4	Uses less fuel					
B5	Annoys other drivers					
B6	Holds up traffic					
B7	Takes me longer to reach my destination					
B8	Makes me feel annoyed					
B9	Makes me feel relaxed					
B10	Makes me feel bored					
B11	Makes me feel safer					
B12	Makes it easier to detect hazards					
B13	Makes me feel more in control of my vehicle					

Section C

C1	You see a speed limit sign ahead indicating a higher maximum speed is allowed. When is it legal to start accelerating to the higher speed?		When you first see the sign 200 feet before the sign 500 feet before the sign Exactly at the sign 200 feet after the sign
C2	Speed limits are designed for ideal road conditions.		True False
C3	Unless otherwise posted, the speed limit is 45 mph in North Carolina cities and towns.		True False
C4	In North Carolina, the speed limit on interstates is ____ mph unless otherwise posted.		75 70 65 60 55
C5	When following another vehicle, allow at least ____ seconds between the time the vehicle ahead of you passes a given point and the time your vehicle reaches the same point.		1 2 3 4 5
C6	On the open road, you should keep enough distance between you and the vehicle ahead so that a passing vehicle can safely move into and occupy the space.		True False
C7	It is legal to exceed the speed limit to pass a vehicle.		True False
C8	If you increase speed and fail to give way to a passing vehicle, you will be charged with a misdemeanor if a crash occurs resulting in bodily injury or property damage.		True False
C9	Under which of the following conditions can you legally pass another vehicle		Wherever there is a solid yellow line on your side of the road Wherever there is a double solid yellow line At a marked crosswalk where another car has stopped to let a pedestrian cross None of the above
C10	In North Carolina, your driver’s license can be suspended if you accumulate ____ points in a three-year period.		___ points in a three-year period
C11	In North Carolina, how many points do you get on your license for each of the following offenses Speeding in a school zone Speeding in excess of 55 mph Reckless driving Running through a red light		a. ___ points b. ___ points c. ___ points d. ___ points
C12	If your speed is over 55 mph and you are driving more than 15 mph over the limit, your driver’s license will be revoked for at least 30 days if you are convicted.		True False
C13	The DMV can suspend your license for which of the following		Two convictions of speeding over 55 mph within a period of 12 months One conviction of speeding over 55 mph and one conviction of reckless driving within a year A conviction of willful racing with another motor vehicle, whether it is prearranged or unplanned All of the above
C14	When a vehicle driving 30 MPH hits a pedestrian, the person survives ____ % of the time?		40% 55% 75% 100%1.
C15	An orange work zone sign means that a driver must:		Continue driving at the same speed Slow down to the posted speed limit Pull over to the side of the road Travel as fast as traffic is moving
C16	In North Carolina, behaviors considered “reckless” or “careless” include all of the following except:		Swerving aggressively Failing to use a turn signal when changing lanes Running a stop sign or red light Highway racing
C17	Total stopping distance is the sum of the distance your vehicle travels during your reaction time and __________?		Starting speed Braking distance Direction Road curvature
C18	Which of the following is not a factor that affects braking distance?		Air resistance Condition of the tires Condition of the road surface Vehicle fuel economy
C20	As speed doubles, stopping distance ___________________?		Stays the same Doubles Triples Quadruples
C21	When the road is wet, icy, or snowy, the driver should maintain the same speed as on a dry road surface.		True False

Section D

Please circle (O) the best answer.

D1. Which of the following is true about driving on a wet roadway

1. As you driver faster, your tires become less effective

2. Water does not affect cars with good tires

3. Deeper water is less dangerous

4. As you decrease your speed, the roadway becomes more slippery

D2. Increasing your vehicle’s speed ___________

1. Increases your field of vision

2. Decreases your field of vision

3. Makes it easier to see cross traffic

4. Has no effect on your field of vision

D3. The speed at which you drive determines the distance required to stop your vehicle

1. True

2. False

D4. Stopping distances are _______ at higher speeds

1. Longer

2. Shorter

D5. If you are traveling 55 mph, your vehicle requires approximately ____ feet to stop completely

1. 50 feet

2. 100 feet

3. 200 feet

4. 500 feet

D6. Higher speeds lead to a greater risk of a crash and a greater probability of serious injury if one occurs

1. True

2. False

D7. In a crash, the _____ the speed the greater the amount of kinetic energy that must be absorbed by the impact.

1. Higher

2. Lower

D8. Harmful crash injury is the result of “energy interchange.” During a collision, injury results from the transfer of energy to the human body in amounts and at rates that damage cellular structure, tissues, blood vessels and other bodily structures. Of the various forms of energy, which energy transfer is the biggest contributor to injury?

1. Kinetic

2. Thermal

3. Chemical

4. Electrical

5. Radiation

D9. The level of damage to the body will depend on various factors. Which factor plays the most critical role?

1. Shape of the colliding surface

2. Velocity

3. Rigidity of the object

D10. A research indicates that while most vulnerable (unprotected) road users survive if hit by a car travelling 20 mph, the majority (80%) are killed if hit by a car travelling at ____ mph

1. 20 mph

2. 30 mph

3. 40 mph

4. 50 mph

D11. If a child runs out into the road, about 40 feet in front of a car, and the car is travelling at ____ mph, it can just stop before hitting the child

1. 20 mph

2. 30 mph

3. 40 mph

4. 50 mph

D12. A 5% increase in average speed leads to approximately a ___% increase in all injury accidents

1. 5%

2. 10%

3. 15%

4. 20%

Section E

In the next 30 days, how likely are you to drive over the speed limit when…
		Unlikely	Somewhat Unlikely	Neither	Somewhat Likely	Likely
E1	Late or in a rush					
E2	Others are exceeding the speed limit					
E3	In traffic calmed areas (e.g., with small roundabouts, speed bumps, special warning signs, etc.)					
E4	Many pedestrians are around					
E5	On quiet roads in the day					
E6	On quiet roads at night					
E7	On long straight roads					

In the next 30 days, how difficult or easy will it be to avoid driving faster than the speed limit…

Extremely Difficult

Somewhat Difficult

Neither Easy nor Difficult

Somewhat Easy

Extremely Easy

E8 On urban roads











E9 On country roads











E10 On limited access roads or interstates











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NHTSA Form 1495