Form NHTSA 1055 A NHTSA 1055 A Survey on Unreported Crashes: Screener Survey

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SURVEY ON UNREPORTED CRASHES

Below are the screening questions, abstracted from the complete survey. If a person has not had a crash within the past year, he or she will hear only these questions (or fewer questions in many cases).

INTRODUCTION

Hello, I'm __________________ from M.Davis and Company (or ABT SRBI) calling for the U.S. Department of Transportation. We are conducting a national study of Americans' driving habits. (If you would like to learn more about the survey, you can call our toll-free number at 1-888-772-4269 or call Jonathan Walker at 1-202-366-8571).

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-XXXX, with an Expiration Date of mm/dd/yyyy. Public reporting for this collection of information is estimated to be approximately 15 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 Ave SE, Washington, D.C. 20590.

DUMMY QUESTION FOR BIRTHDAY QUESTIONS

Has had the most recent.......1

Will have the next................2

A1. How many persons, age 16 and older, live in this household?

______ Number of 16+ persons

IF ONLY 1 PERSON, SKIP TO A3

(VOL) None........THANK AND SCREEN OUT

Refused…………………….…4 Thank and end, [Soft Refusal]

A2. How many of those adults are (women/men)?

a. ____ women (VOL) None..........00

b. ____ men (VOL) None..........00

Refused…………………….……………………………….99

A3. IF A1 = 1 read"May I please speak to him or her?"

If A1 >1 read "In order to select just one person to interview, may I please speak to the (GENDER, If Refused in A2, read-in: "person") in your household, age 16 or older, who (has had the most recent/will have the next) birthday?"

Designated Respondent on line........…1 GO TO C

Someone else................................….2 GO TO B

SCHEDULE CALLBACK..........…..3

Refused…………………............….4 Thank and end, [Soft Refusal]

B. Hello, I'm _______________ from M. Davis and Company (or SRBI) calling for the U.S. Department of Transportation. We are conducting a national study of Americans' driving habits and their attitudes about current driving laws. (If you would like to learn more about the survey, you can call our toll-free number at 1-888-772-4269 or call Jonathan Walker at 1-202-366-8571)

C. The interview is voluntary and the information you provide us will be used for statistical purposes only. We will not collect any personal information that would allow anyone to identify you. If there is a question you don’t want to answer, that’s OK. The interview takes about 15 - 20 minutes to complete. (This study has been reviewed and approved by the Office of Management and Budget under OMB control number 2127-0645.) Could we begin now?

CONTINUE INTERVIEW................1 SKIP TO Q1

Arrange Callback.................................2

Want to think about it/Not sure…..….3 CALLBACK

Refused................…………… .........4 END INTERVIEW

CRASH EXPERIENCE

Q1. How often do you drive a motor vehicle? Everyday or almost every day, a few days a week, a few days a month, a few days a year, or do you never drive?

Almost every day/every day..........………1

Few days a week.....................................2

Few days a month...........…...........……...3

Few days a year......................................4

Never..........................................……....5

More than a year ago………................…6

(VOL) Other (Specify)……….………..7

(VOL) Don't know................................8

(VOL) Refused............................…….9

Q2a. Have YOU ever been INJURED in a motor vehicle accident in which you were a DRIVER?

Yes......................................1

No.......................................2 SKIP TO Q3a

(VOL) Don't know............…8 SKIP TO Q3a

(VOL) Refused....................9 SKIP TO Q3a

Q2b. When was the most recent time this happened (injured as a driver)? Was it ….

Within the past 6 months………..1

Within the past 12 months………2

Within the past 2 years………….3 SKIP TO Q3a

Within the past 4 years………….4 SKIP TO Q3a

Four or more years ago…………5 SKIP TO Q3a

Q3a. Have YOU ever been INJURED in a motor vehicle accident when you were a PASSENGER?

Yes......................................1

No.......................................2 SKIP TO Q4a

(VOL) Don't know..........…..8 SKIP TO Q4a

(VOL) Refused....................9 SKIP TO Q4a

Q4a. Have YOU ever been hit by a motor vehicle and INJURED when you were a pedestrian, that is, not traveling in a motor vehicle at the time of the accident?

Yes......................................1

No.......................................2 SKIP TO Q5a

(VOL) Don't know.........…...8 SKIP TO Q5a

(VOL) Refused....................9 SKIP TO Q5a

Q5a. Aside from what you have already told me, have you ever been in a motor vehicle accident in which YOUR VEHICLE was damaged?

Yes......................................1

No.......................................2 SKIP TO direction before Q6

(VOL) Don't know........…....8 SKIP TO direction before Q6

(VOL) Refused..............…...9 SKIP TO direction before Q6

Q6. Has anyone else in the household been in a motor vehicle crash in the past twelve months that involved either injury or property damage?

Yes ASK TO SPEAK TO THE PERSON (GO TO B)

No THANK AND END

(VOL) Don’t Know THANK AND END

(VOL) Refused THANK AND END

NHTSA 1055A