Form 1604 Screener Form

OMB Control No. 2127-NEW

Expiration Date: XX/XX/XX

Screener Form

Under the Paperwork Reduction Act, a Federal agency may not conduct or sponsor, and a person is not required to respond to 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-XXXX (expiration date: XX/XX/XXXX). The average amount of time to complete the screener form is 1 minute. All responses to this collection of information are voluntary. The purpose of this research study is to examine public attitudes toward motor vehicle safety and relationships between attitudes, behaviors, and demographics. The information collected will be summarized in a report to support future countermeasure development. 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.

Screening Question	Response Options	Respondents will not see the inclusion and exclusion criteria
		Include	Exclude
Do you live in the United States?	YES NO	YES	NO
Are you age 18 or older?	YES NO	YES	NO
If you live in Nebraska, are you age 19 or older?	YES NO Not Applicable	YES, Not Applicable	NO
If you live in Alabama, are you age 19 or older?	YES NO Not Applicable	YES, Not Applicable	NO
If you live in Mississippi, are you age 21 or older?	YES NO Not Applicable	YES, Not Applicable	NO
Are you able to read and write in English fluently?	YES NO	YES	NO
Have you driven a car, van, SUV, or pickup truck at least once in the past month?	YES NO	YES	NO
Do you drive a motorcycle as your main form of transportation?	YES NO	NO	YES
When is the last time that you did not wear a seat belt when driving? (Check one.)	Today Within the past week Within the past month Within the past 12 months A year or more ago Not applicable: I have worn a seat belt every time I have driven.	Today Within the past week Within the past month Within the past 12 months A year or more ago Not applicable: I have worn a seat belt every time I have driven.	Blank Response

For the last screening question, potential participants who respond either 1, 2, 3, or 4 will be identified as Part Time Seat Belt Users or Not Seat Belt Users when they are driving. Potential participants who respond either 5 or 6 will be identified as Full Time Seat Belt Users when they are driving.

If potential participants qualify, they will read, “You have been qualified for the study” with an accompanying link to the informed consent.

If potential participants qualify in one of the groups, but the number needed for that group has been filled, they will read, “Unfortunately, the study is full for participants. Thank you for your time and consideration.”

If potential participants do not qualify, they will read, “Unfortunately, you do not qualify for the study. Thank you for your time and consideration.”

NHTSA Form No. 1604