Attachment 2 – Instrument to be evaluated through focus groups (self-administered) and one-on-one cognitive interviews (interviewer administered)
Public reporting burden for this collection of information is estimated to average 30 minutes per response for focus groups and 60 minutes per response for one-on-one cognitive interviews, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).
OMB #0920-0222; Expiration Date: 02/28/10
Youth Traffic Safety Questionnaire
Vehicle Use
1. How often do you drive a motor vehicle? Almost everyday, a few days a week, a few days a month, a few days a year, or do you never drive?
almost everyday (accept “every day”)
a few days a week
a few days a month
a few days a year
never (go to Belts, #1)
2. Is the vehicle you drive most often a car, van, motorcycle, sports utility vehicle, pickup truck, or other type of truck? (If respondent drives more than one vehicle often, ask:) “What kind of vehicle did you last drive?”
Car
Van or minivan
Motorcycle
Sports utility vehicle
Pickup truck
Other type of truck (specify) _______________________
Other (specify) __________________________________
3. Who owns the vehicle that you drive most often? Is it you, your parent or guardian, or someone else? [accept multiple responses]
□ Self
□ Parent
□ Guardian—if “guardian” offered, substitute this for “parent” in subsequent questions.
□ Someone else’s (specify) ___________________________
4. Who pays for the insurance of the vehicle you drive most often? Is it you, your parents, both you and your parents, someone else, or is there no insurance on the vehicle?
a) self
b) parents/guardians
c) both self and parents
d) someone else (specify) ________________________________
e) no insurance on the vehicle
5. Which of the following statements best describes the times that you drive:
a) I do all of my driving during the daytime
b) I do most of my driving during the day, but some after dark
c) I drive about equally during the day and after dark
d) I do most of my driving after dark
e) I do all of my driving after dark
6. Thinking about all the times that you drive, how often do you have one or more passengers in the vehicle with you? Would you say:
a) Almost everyday (accept “every day”)
b) a few days a week
c) a few days a month
d) a few days a year
e) never
7. When you are driving and are not alone in the vehicle, how many passengers do you usually have?
_______
Note: Questions 8a-12 -- alternative ways of asking the questions above.
8a. How often do you drive a motor vehicle at night, after 9:00 PM? Do you drive at night almost every day, a few days a week, a few days a month, a few days a year, or do you never drive after 9:00 PM at night?
Almost everyday (accept “every day”)
a few days a week
a few days a month
a few days a year
never
8b. How often do you drive during the daytime? Would you say…
Almost everyday (accept “every day”)
a few days a week
a few days a month
a few days a year
never
How often do you drive by yourself?
Almost everyday (accept “every day”)
a few days a week
a few days a month
a few days a year
never
10. Do you have any younger brothers or sisters?
Yes (continue)
No (skip to Q11)
10a. (If yes) On average, how often are any of your younger brothers or sisters in the car with you while you are driving?
Almost everyday (accept “every day”)
a few days a week
a few days a month
a few days a year
never
11. (If yes to 10, read “Not counting your younger brothers or sisters…”) How often do you drive with passengers who are under the age of 21?
Almost everyday (accept “every day”)
a few days a week
a few days a month
a few days a year
never
12. How often do you drive with adult passengers, 21 years old or older?
Almost everyday (accept “every day”)
a few days a week
a few days a month
a few days a year
never
13. Have your parents set any rules to control or restrict...
The time of night that you are allowed to drive □yes □no
The number of passengers that you are allowed to drive □yes □no
The age of the passengers that you are allowed to drive □yes □no
Graduated Driver Licensing/Driver Education
What state do you currently live in?
--------------------------------------
2. Does your state have a graduated driver licensing program? This means that after the learner’s permit, teenagers must drive for a period of time with a provisional license before they can get the same driver’s license adults have. A provisional license has special rules a driver must follow.
a) yes
b) no-- skip
c) don’t know/ not sure
3. As far as you know, what are the conditions that are placed on drivers when they first receive Learner’s Permits in your state?
4. As far as you know, what are the conditions that are placed on drivers when they first receive a Provisional License in your state?
5. Which of the following describes your own license for driving:
a) I have a full driver’s license, with no provisions
b) I have a Provisional Driver’s License
c) I have a Learner’s Permit
d) I do not have a Learner’s Permit or any kind of driver’s license.
5a. (Skip if Q5=d) How long have you had your [response from Q5]?
6a. (If Q5=d, no Learner’s Permit, ask:) Have you received any kind of driver’s education?
a) Yes
b) No—Skip to Q7
6b. Where did you receive your driver’s education? Was it from a course at school, a course from a private company, a course from the Internet, or some other kind of driver’s education?
a) Course at school
b) Private company
c) Internet
d) Other—specify __________________________
7. How helpful would you say this course was for passing the test to receive your driver’s license? Would you say…
a) Very helpful
b) Somewhat helpful
c) A little helpful
d) Not very helpful
8. How helpful would you say this course was for learning good driving skills. Would you say…
a) Very helpful
b) Somewhat helpful
c) A little helpful
d) Not very helpful
9a. (Ask only if respondent has Provisional or Full License; else skip to Q10) How closely did/do your parents require you to follow the conditions that were placed on your Provisional License?
a) Exactly
b) Very closely
c) Somewhat closely
d) Not closely
9b. How closely did/do you follow the conditions that were placed on your Provisional License?
a) Exactly
b) Very closely
c) Somewhat closely
d) Not closely
10a. (Ask if respondent has a Learner’s Permit, Provisional License, or Full License; else skip to Q11) How closely did your parents require you to follow the conditions that were placed on your Learner’s Permit?
a) Exactly
b) Very closely
c) Somewhat closely
d) Not closely
10b. How closely did you follow the conditions that were placed on your Learner’s Permit?
a) Exactly
b) Very closely
c) Somewhat closely
d) Not closely
11. How likely do you think it is that drivers who violate conditions of graduated driver licenses will be stopped by the police?
a) Very likely
b) Somewhat likely
c) A little likely
d) Not likely
12. If police stop a driver who has violated conditions of provisional license, what do you think is most likely to happen?
a) Nothing
b) They would receive a warning
c) They would receive a ticket
d) Their license would be suspended
e) Their license would be taken away
Cell Phone Use
1. When you drive a motor vehicle, do you usually have a wireless phone of some type in the vehicle with you? This could be a car phone, a cellular phone, a PCS phone, a GSM phone, or a satellite phone.
a. Yes
b. No
2. How often do you talk on the phone while you are driving?
a. Always
b. Most of the time
c. Some of the time
d. Rarely
e. Never (skip to 4)
3. When you talk on the phone while driving, do you usually
______ Hold the phone
______ Use a hands-free set
4. If you are driving and your phone rings, do you usually:
_____ Answer the phone
_____ Look to see who is calling, then decide whether to answer the phone
_____ Ignore it until later
_____ (If volunteered) Never rings while driving/I turn it off
5. How often do you read text messages while you are driving?
a) Almost everyday (accept “every day”)
b) a few days a week
c) a few days a month
d) a few days a year
e) never
6. How often do you send text messages while you are driving?
a) Almost everyday (accept “every day”)
b) a few days a week
c) a few days a month
d) a few days a year
e) never
Belts
When you are driving a motor vehicle, how often do you wear a seatbelt?
all of the time
most of the time
some of the time
rarely
never
2. When was the last time that you did not wear a seat belt while driving—was it
a) within the past week
b) within the past month
c) within the past year
d) more than a year ago
e) never—Skip to Q3
2a. The last time that you were driving without wearing a seat belt, was anyone else in the vehicle with you?
a) Yes
b) No—Skip to Q3
2b. Who was in the vehicle with you the last time you were driving without wearing a seat belt? (check all that apply)
___ Friends
___ Brothers or sisters
___ Parents
___ Someone else (specify) ___________
3. Do you ever ride as a passenger in the front seat of a motor vehicle?
a) yes
b) no—Skip to Q6
4. When you are a passenger in the front seat of a motor vehicle, how often do you wear a seatbelt?
a) all of the time
b) most of the time
c) some of the time
d) rarely
e) never
5. When was the last time that you did not wear a seat belt when you were a passenger in the front seat of a motor vehicle—was it
a) within the past week
b) within the past month
c) within the past year
d) more than a year ago
e) never—Skip to Q6
5a. The last time that you were a passenger in the front seat and were not wearing a seat belt, who was driving the motor vehicle?
a) a parent
b) a friend
c) a brother or sister
d) someone else (specify) ___________
5b. Who else was in the vehicle with you the last time you were a passenger in the front seat and were not wearing a seat belt? (check all that apply)
___ Friends
___ Brothers or sisters
___ Parents
___ Someone else (specify) ___________
___ No one else
6. Do you ever ride as a passenger in the front seat of a motor vehicle?
a) yes
b) no—Skip to Q9
7. When you are a passenger in the front seat of a motor vehicle, how often do you wear a seatbelt?
a) all of the time
b) most of the time
c) some of the time
d) rarely
e) never
8. When was the last time that you did not wear a seat belt when you were a passenger in the front seat of a motor vehicle—was it
a) within the past week
b) within the past month
c) within the past year
d) more than a year ago
e) never—Skip to Q9
8a. The last time that you were a passenger in the front seat and were not wearing a seat belt, who was driving the motor vehicle?
a) a parent
b) a friend
c) a brother or sister
d) someone else (specify) ___________
8b. Who else was in the vehicle with you the last time you were a passenger in the front seat and were not wearing a seat belt? (check all that apply)
___ Friends
___ Brothers or sisters
___ Parents
___ Someone else (specify) ___________
___ No one else
9. How often do your parents usually wear their seatbelts?
all of the time
most of the time
some of the time
rarely
never
10. Do you tend to wear your seatbelt less often than usual when…
a. You are riding or driving with friends? □yes □no
You are going a short distance? □yes □no
You are riding or driving after dark? □yes □no
You are not in your own vehicle? □yes □no
You are just a passenger in a vehicle? □yes □no
You are driving alone? □yes □no
Police Stops/Enforcement
1. In the past 12 months, how many times have you been stopped by the police while driving a motor vehicle?
_____ [NUMBER]
2. Of the times you were stopped, how many times did the officer let you go with only a warning?
3. Of the times you were stopped, how many times did you receive a ticket?
4. What was/were the reasons for the ticket (s): [count all that apply; do not read categories]
_____ Speeding
_____ Running a red or yellow light
_____ Driving without a seat belt
_____ failure to use a turn signal
_____ careless or reckless driving
_____ failure to stop at a stop sign
_____ using a wireless phone while driving
___________________________ other (specify)
5. In the past 12 months, how many times have you been a passenger in a vehicle that was stopped by the police?
Crash Experience
1. Regardless of who was at fault, have you ever been the driver of a vehicle involved in a crash or accident? (If no, skip to Q5)
2. How many times have you been the driver of a vehicle that was involved in a crash or accident?
3. In how many of these crashes or accidents where you were driving were you wearing a seat belt?
4. In how many of these crashes or accidents where you were driving were you injured seriously enough that you received medical attention?
5. Have you ever been a passenger in a vehicle involved in a crash or accident?
6. How many times have you been a passenger in a vehicle that was involved in a crash or accident?
7. In how many of these crashes or accidents where you were a passenger were you wearing a seat belt?
8. In how many of these crashes or accidents where you were driving were you injured seriously enough that you received medical attention?
Alcohol Attitudes and Behavior
The next questions are about alcoholic beverages. By alcoholic beverages, we mean a can of beer, glass of wine or wine coolers, shot of liquor or a mixed drink.
1. In your entire life, have you had a total of five or more alcoholic beverages?
□yes
□no
1a. (If Q1=no) Have you ever had an alcoholic beverage? If you have only had sips or part of an alcoholic beverage, please answer no.
□yes (continue)
□no (go to Intro, Q8)
2. When was the most recent time that you had an alcoholic beverage? Was it
_____ Within the past week
_____ Within the past month
_____ Within the past year
_____ More than a year ago
3. We are interested in the first time you had an alcoholic beverage. Please do not count sips. How old were you the first time you had an alcoholic beverage, meaning a can of beer, glass of wine, or liquor by the “shot” or in mixed drink?
_____ age in years
_____ Never had a whole alcoholic beverage
4. In the past 12 months, how often did you drink any kind of alcoholic beverage?
(If necessary, read: “How many days per week, month, or year did you drink alcohol?”)
_____ times per ___ (if > 0)
a. week
b. month
c. year
5. (Skip of Q4=0) In the past year, on those days that you drank alcoholic beverages, how many alcoholic drinks did you usually have?
______ number of drinks
6. In the past 12 months, how many times, if ever, have you been drunk or very buzzed from drinking alcoholic beverages? Would you say…
a. Never
b. One or two times
c. Three to five times
d. More than five times
7. (Skip if Q6=never) How old were you the first time you were drunk or very buzzed from drinking alcoholic beverages?
The next questions are about ways that people can get alcoholic beverages. Please remember that your answers are confidential.
8. If you wanted to obtain an alcoholic beverage, how easy or difficult would it be? Would you say:
____ It would be very easy
____ It would be somewhat easy
____ It would be neither easy nor difficult
____ It would be somewhat difficult
____ It would be very difficult
9. Please let me know whether you agree or disagree with the following statements:
a. If I wanted to get an alcoholic beverage, I would probably be able to buy one myself
b. Either I or a friend have a fake ID that could be used to purchase alcoholic beverages
c. I know one or more people over the age of 21 who would be willing to buy alcoholic beverages for me
d. I know of one or more stores or bars that are willing to sell alcoholic beverages to people under 21
e. I could probably get alcoholic beverages that belong to my parents, or to the parents of someone else that I know
f. I know some parents that provide alcohol to their kids and their friends who are under 21
10. When you drink alcoholic beverages, were they usually provided by
a. You
b. A friend
c. A member of your family
d. Someone you do not know well
11. I am going to read a list of places where people can drink alcoholic beverages. For each one, please tell me whether you drink alcohol there never, rarely, sometimes, or often.
a. A bar or club
b. A restaurant
c. My own house
d. The house of a friend or family member
e. The house of an acquaintance or someone I don’t know well
f. A car
g. A private outdoor place, such as the woods or a parking lot
12a. In the past 30 days, how many times, if any, have you been a passenger in a motor vehicle when the driver had been drinking one or more alcoholic beverages?
(If self-admin, use categories; else open-ended response)
___ None
___ Once
___ Twice
___ 3-5 times
___ 6-9 times
___ 10 or more times
12b. In the past 30 days, how many times, if any, have you been a passenger in a motor vehicle when you think the driver had 5 or more alcoholic beverages?
(If self-admin, use categories; else open-ended response)
___ None
___ Once
___ Twice
___ 3-5 times
___ 6-9 times
___ 10 or more times
13a. In the past 30 days, how many times, if any, have you driven a motor vehicle after drinking one or more alcoholic beverages?
(If self-admin, use categories; else open-ended response)
___ None
___ Once
___ Twice
___ 3-5 times
___ 6-9 times
___ 10 or more times
13b. In the past 30 days, how many times, if any, have you driven a motor vehicle after having 5 or more alcoholic beverages?
(If self-admin, use categories; else open-ended response)
___ None
___ Once
___ Twice
___ 3-5 times
___ 6-9 times
___ 10 or more times
The next questions are about your opinion—there are no right or wrong answers.
14. How many alcoholic beverages do you think the average person your age could have before they would not be able to drive safely?
15. How many alcoholic beverages do you think the average person your age could have before they would be likely to be pulled over by the police?
16. When a police officer stops a driver, how many alcoholic beverages do you think the driver could have had before he or she would get arrested?
17. How active would you say the police are about enforcing drinking and driving laws in your community? Would you say they are:
a) very active
b) somewhat active
c) slightly active
d) not at all active
The next few questions are about your parents.
18. As far as you know, does one or more of your parents drink alcoholic beverages at least once a year?
19. Please think about the parent who drinks alcoholic beverages most often. Which of the following comes closest to describing how often this parent drinks alcoholic beverages?
___ almost every day
___ a few days a week
___ a few days a month
___ a few days a year
20. Do you believe that your parents think you drink alcohol
___ less often than you actually do
___ more often than you actually do
___ or about as often as you actually do?
Speed
1. Which statement best describes your driving on main roads in your community? I tend to pass other cars more often than other cars pass me, or other cars tend to pass me more often
2. How fast do you usually drive on main roads in your community?
___ MPH
3. Please tell me whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with the following statement: “If someone is a good driver, they can drive fast safely.” (Repeat if necessary: Would you say you strongly agree…)
4. Suppose a road has a posted speed limit of 45 miles per hour. Do you think that a good driver can safely drive at: (read each until a “no” response is given).
a. 55 miles per hour?
b. 65 miles per hour?
c. 75 miles per hour?
4-ALT Suppose a road has a posted speed limit of 45 miles per hour. In your opinion, if a good driver goes 20 miles per hour over the speed limit, is that …
_____ Just as safe as going the speed limit
_____ Almost as safe as going the speed limit
_____ Somewhat more dangerous than going the speed limit
_____ A lot more dangerous than going the speed limit
The next questions are about racing. By racing, we mean any time that two or more drivers are trying to go faster in their vehicles than each other. Racing can be for short or long distances, and might be done on public roads or on tracks or racing strips.
5. In the past 12 months, have you ever raced while driving a motor vehicle?
5a. (If Q5=no, Skip to Q6) In the past 12 months, how many times have you raced while driving a motor vehicle.
5b. The last time you raced in a motor vehicle, how many people were in the vehicle with you?
6. In the past 12 months, have you ever been a passenger in a motor vehicle that was racing another motor vehicle?
6a. (If Q6=no, Skip to Q7) In the past 12 months, how many times have you been a passenger in a motor vehicle that was racing another motor vehicle?
6b. The last time you raced in a motor vehicle, how many people were in the vehicle with you?
The next questions are about your opinions about racing.
7. Do you think racing another vehicle is…
_____ Very dangerous
_____ Somewhat dangerous
_____ A little dangerous
_____ Not at all dangerous
8. Do you think the idea of racing another vehicle sounds…
_____ Very exciting
_____ Somewhat exciting
_____ A little exciting
_____ Not at all exciting
Demographics
Gender
a) female
b) male
Do you consider yourself to be Hispanic or Latino?
a) yes
no
3. What race or races do you consider yourself to be? (select all)
a) American Indian or Alaska Native
b) Black or African American
b) Asian
c) Native Hawaiian or other Pacific Islander
c) White
4. How old are you?
_______ [AGE IN YEARS]
5. Are you currently a full-time student, part-time student, or not a student?
a) full time student
b) part time student
c) not a student
6. Are you currently employed full-time, part-time, or are you not employed?
a) full-time
b) part-time
c) not employed
In what type of residence do you live?
_____ In a house with my parents
_____ In an apartment with my parents
_____ In an apartment without my parents
_____ In a dormitory without my parents
The next question is about your parents’ income in the past year [2006]. If you do not know this information for sure, please just answer to the best of your knowledge. Would you say your parents’ total annual income in the past year is more or less than $60,000 per year?
a) More than $60,000—go to Q9a
b) Less than $60,000—go to Q9b
c) (If offered)—About $60,000—go to 10
d) DK/Refused—go to 10
9a. Would you say your parents’ total annual income in the past year is more or less than $100,000 per year?
a) More than $100,000
b) Less than $100,000
c) (If offered)—About $100,000
d) DK/Refused -- GO TO Q10
9b. Would you say your parents’ total annual income in the past year is more or less than $40,000 per year?
a) More than $40,000
b) Less than $40,000
c) (If offered)—About $40,000
d) DK/Refused
10. And what about you personally—what was your own annual income in the past year [2006]? Please include income from any jobs, interest on bank accounts, or other income that you received.
11. Which of the following describes the education that your father received? Would you say he:
_____ Did not complete high school
_____ Graduated from High school
_____ Has some college
_____ Has a college degree
_____ Has a master’s degree
_____ Has an advanced professional degree such a medical degree, law degree, or doctorate?
_____ (Do not read) DK/Refused
12. Which of the following describes the education that your mother received? Would you say he:
_____ Did not complete high school
_____ Graduated from High school
_____ Has some college
_____ Has a college degree
_____ Has a master’s degree
_____ Has an advanced professional degree such a medical degree, law degree, or doctorate?
_____ (Do not read) DK/Refused
13. What is the zip code of the home where your parents live?
______ (5-digit zip code)
______ DK/Refused
14. How often do your parents do any of the following:
a) Check on how well you are doing in school. Would you say…
_____ Often
_____ Sometimes
_____ Rarely
_____ Never
b) Pay attention to who your friends are and who you spend time with
_____ Often
_____ Sometimes
_____ Rarely
_____ Never
c) Talk with you about what is going on in your life
_____ Often
_____ Sometimes
_____ Rarely
_____ Never
Set restrictions on how late you can stay out
_____ Often
_____ Sometimes
_____ Rarely
_____ Never
e) Set restrictions on what you watch on TV
_____ Often
_____ Sometimes
_____ Rarely
_____ Never
f) Set restrictions on your use of the Internet
_____ Often
_____ Sometimes
_____ Rarely
_____ Never
15. Suppose you were having problems in your life. Do you think you would talk over most problems with your parents, some problems with your parent, or that you probably would not discuss problems with your parents?
____ Would discuss most/all problems with parents
____ Would discuss some problems with parents
____ Would not discuss problems with parents
| File Type | application/msword |
| File Title | Attachment 2 – Instrument to be evaluated through focus groups (self-administered) and one-on-one cognitive interviews (intervie |
| Author | Karen Whitaker |
| Last Modified By | ziy6 |
| File Modified | 2007-04-20 |
| File Created | 2007-04-20 |