OMB #2127-0646 Expiration Date: August 31, 2011
National Click It or Ticket Mobilization
Hello, I'm ______________ calling for the U.S. Department of Transportation.
We are conducting a study of Americans' driving habits and attitudes.
The interview is voluntary and the information you provide us will be used for statistical purposes only.
Please note: 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 2127-0646. Public reporting for this collection of information is estimated to be approximately 10 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, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590
Q.1
How often do you drive a motor vehicle? Almost every day, a few days
a week, a few days a month, a few days a year, or do you never drive?
1 Almost every day
2 Few days a week
3 Few days a month
4 Few days a year
5 Never (SKIPTO Q9)
6 Other (SPECIFY)
7 (VOL) Don't know
8 (VOL) Refused
Q.2
Is the vehicle you drive most often a car, van, motorcycle, sport utility
vehicle, pickup truck, or other type of truck?
NOTE:IF RESPONDENT DRIVES MORE THAN ONE VEHICLE OFTEN, ASK:
"What kind of vehicle did you LAST drive?"
01 Car
02 Van or minivan
03 Motorcycle (SKIPTO Q9)
04 Pickup truck
05 SUV (Sport Utility Vehicle)
10 Other (specify)
11 Other truck (SPECIFY)
12 (VOL) Don't know
13 (VOL) Refused
Q.2b
How much of your driving is done between Midnight and 4:00AM?
1 None/Almost None
2 A lot less than half
3 About half
4 A lot more than half
5 All/Almost all
6 (DO NOT READ) Don't know
7 (DO NOT READ) Refused
Q.2c
When you pass a driver stopped by the police in the daytime, what do you think the stop was for?
1 Speeding
2 Seat belt violation
3 Drunk driving
4 Reckless driving
5 Registration Violation
6 Distracted driving, cell phone/ texting etc
7 Other (Specify)
Q.2d
When you pass a driver stopped by the police at night, what do you think
the stop was for?
1 Speeding
2 Seat belt violation
3 Drunk driving
4 Reckless driving
5 Registration Violation
6 Distracted driving cell phone/ texting etc
7 Other (Specify)
Q.3
For the next series of questions, please answer only for the [Vehicle]
you said you usually drive. Do the seat belts in the front seat of the
[Vehicle] go across your shoulder only, across your lap only, or
across both your shoulder and lap?
INTERVIEWER INSTRUCTION: SEATBELT QUESTIONS REFER TO DRIVER SIDE BELTS.
1 Across shoulder
2 Across lap (SKIPTO Q5)
3 Across both
4 Vehicle has no belts (SKIPTO Q9)
5 (VOL) Don't know (SKIPTO Q6)
6 (VOL) Refused (SKIPTO Q6)
Q.4
When driving this [Vehicle], how often do you wear your shoulder
belt...
(READ LIST)
1 ALL OF THE TIME
2 MOST OF THE TIME
3 SOME OF THE TIME
4 RARELY OR
5 NEVER
6 (VOL) Don't know
7 (VOL) Refused
GO TO Q6
IF: (Q3 is Across shoulder )
Q.5
When driving this [Vehicle], how often do you wear your lap belt...
(READ LIST)
1 ALL OF THE TIME
2 MOST OF THE TIME
3 SOME OF THE TIME
4 RARELY OR
5 NEVER
6 (VOL) Don't know
7 (VOL) Refused
Q.6
When was the last time you did NOT wear your seat belt when driving?
1 Within the past day
2 Within the past week
3 Within the past month
4 Within the past year
5 A year or more ago/I always wear it
6 (VOL) Don't know
7 (VOL) Refused
Q.7
In the past 30 days, has your use of seat belts when driving a [Vehicle]
increased, decreased, or stayed the same?
1 Increased
2 Decreased (SKIPTO Q9)
3 Stayed the same (SKIPTO Q9)
4 New driver (SKIPTO Q9)
5 (VOL) Don't know (SKIPTO Q9)
6 (VOL) Refused (SKIPTO Q9)
Q.8
What caused your use of seat belts to increase?
DO NOT READ LIST - MULTIPLE RECORD
01 Increased awareness of safety
02 Seat belt law
03 Don't want to get a ticket
04 Was in a crash
05 New car with automatic belt
06 Influence/pressure from others
07 More long distance driving
08 Remember more/more in the habit
09 The weather
10 The holidays
11 Driving faster
27 Other (SPECIFY)
28 - (VOL) Don't know
29 - (VOL) Refused
Q.9
Does [State] have a law requiring seat belt use by adults?
1 Yes
2 No (SKIPTO Q12)
3 (VOL) Don't know (SKIPTO Q12)
4 (VOL) Refused (SKIPTO Q12)
GOTO Q11
IF: (Q1 is Never AND Q9 is Yes )
IF: (Q2 is Motorcycle AND Q9 is Yes )
Q.10
Assume that you do not use your seat belt AT ALL while driving over the next
six months. How likely do you think you will be to receive a ticket for not
wearing a seat belt?
READ LIST
1 Very likely
2 Somewhat likely
3 Somewhat unlikely
4 Very unlikely
5 (VOL) Don't know
6 (VOL) Refused
Q.10a
When driving this [Vehicle] AT NIGHT (after midnight) how
often do you wear your shoulder belt...
(READ LIST)
1 All of the time
2 Most of the time
3 Some of the time
4 Rarely or
5 Never
6 (DO NOT READ) Don't know
7 (DO NOT READ) Refused
GOTO Q10C
IF: (Q3 is Across shoulder )
Q.10b
When driving this [Vehicle] AT NIGHT (after midnight) how
often do you wear your lap belt...
(READ LIST)
1 All of the time
2 Most of the time
3 Some of the time
4 Rarely or
5 Never
6 (DO NOT READ) Don't know
7 (DO NOT READ) Refused
Q.10c
When was the last time you did NOT wear your seat belt when driving
AT NIGHT (after midnight)?
1 Within the past day
2 Within the past week
3 Within the past month
4 Within the past year
5 A year of more ago/I always wear it
6 (DO NOT READ) Don't know
7 (DO NOT READ) Refused
Q.10d
In the past 30 days, has your use of seat belts when driving, AT NIGHT
(after midnight), your [Vehicle] increased, decreased or
stayed the same?
1 Increased
2 Decreased (SKIPTO B4_Q10F)
3 Stayed the same (SKIPTO B4_Q10F)
4 New driver (SKIPTO B4_Q10F)
5 (DO NOT READ) Don't know (SKIPTO B4_Q10F)
6 (DO NOT READ) Refused (SKIPTO B4_Q10F)
Q.10e
What caused your use of seat belts to increase?
(DO NOT READ LIST)
(ENTER ALL RESPONSES THAT APPLY)
01 Increased awareness of safety
02 Seat belt law
03 Don't want to get a ticket
04 Was in a crash
05 New car with automatic belt
06 Influence/pressure from others
07 More long distance driving
08 Remember more/more in the habit
09 The weather
10 The holidays
11 Drive faster
27 Other (specify)
28 - Don't know
29 - Refused
GOTO Q11
IF: (Q1 is Never AND Q9 is Yes )
GOTO Q11
IF: (Q2 is Motorcycle AND Q9 is Yes )
Q.10f
Assume that you do not use your seat belt AT ALL, while driving over the next six months. How likely do you think you will be to receive a ticket for not wearing a seat belt?
(READ LIST)
1 Very likely
2 Somewhat likely
3 Somewhat unlikely
4 Very unlikely
5 (DO NOT READ) Don't know
Q.11
According to your state law, can police stop a vehicle if they observe a seat belt violation or do they have to observe some other offense first in order to stop the vehicle?
1 Can stop just for seat belt violation
2 Must observe another offense first
3 (VOL) Don't know
4 (VOL) Refused
Q.12
In your opinion, SHOULD police be allowed to stop a vehicle if they
observe a seat belt violation when no other traffic laws are being broken?
1 Should be allowed to stop
2 Should not
3 (VOL) Don't know
4 (VOL) Refused
Q.13A
Please tell me whether you strongly agree, somewhat agree, somewhat disagree
or strongly disagree with the following statements?
Seat belts are just as likely to harm you as help you.
1 Strongly Agree
2 Somewhat Agree
3 Somewhat Disagree
4 Strongly Disagree
5 (VOL) Don't know
6 (VOL) Refused
Q.13B
Please tell me whether you strongly agree, somewhat agree, somewhat disagree
or strongly disagree with the following statements?
If I was in an accident, I would want to have my seat belt on.
1 Strongly Agree
2 Somewhat Agree
3 Somewhat Disagree
4 Strongly Disagree
5 (VOL) Don't know
6 (VOL) Refused
Q.13C
Please tell me whether you strongly agree, somewhat agree, somewhat disagree
or strongly disagree with the following statements?
Police in my community generally will not bother to write tickets for seat belt violations.
1 Strongly Agree
2 Somewhat Agree
3 Somewhat Disagree
4 Strongly Disagree
5 (VOL) Don't know
6 (VOL) Refused
Q.13D
Please tell me whether you strongly agree, somewhat agree, somewhat disagree
or strongly disagree with the following statements?
It is important for police to enforce the seat belt laws.
1 Strongly Agree
2 Somewhat Agree
3 Somewhat Disagree
4 Strongly Disagree
5 (VOL) Don't know
6 (VOL) Refused
Q.13E
Please tell me whether you strongly agree, somewhat agree, somewhat disagree
or strongly disagree with the following statements?
Putting on a seat belt makes me worry more about being in an accident.
1 Strongly Agree
2 Somewhat Agree
3 Somewhat Disagree
4 Strongly Disagree
5 (VOL) Don't know
6 (VOL) Refused
Q.13F
Please tell me whether you strongly agree, somewhat agree, somewhat disagree
or strongly disagree with the following statements?
Police in my community are writing more seat belt tickets now than they were a few months ago.
1 Strongly Agree
2 Somewhat Agree
3 Somewhat Disagree
4 Strongly Disagree
5 (VOL) Don't know
6 (VOL) Refused
Q.13G
Please tell me whether you strongly agree, somewhat agree, somewhat disagree
or strongly disagree with the following statements?
Police in my community are writing seat belt tickets for seatbelt violations they see at night.
1 Strongly Agree
2 Somewhat Agree
3 Somewhat Disagree
4 Strongly Disagree
5 (VOL) Don't know
6 (VOL) Refused
Q.14
Yes or No--in the past 30 days, have you seen or heard of any special effort
by police to ticket drivers in your community for seat belt violations?
1 Yes
2 No (SKIPTO Q17)
3 (Vol) Don't know (SKIPTO Q17)
4 (Vol) Refused (SKIPTO Q17)
Q.15
Where did you see or hear about that special effort?
[DO NOT READ--MULTIPLE RESPONSE]
01 TV
02 Radio
03 Friend/Relative
04 Newspaper
05 Personal observation/on the road
07 Billboard/signs
08 Educational Program
09 I'm a police officer/judge
10 Direct contact by police officer
11 Internet/online/computer game/email (not from friend)/social network/mobile phone internet/web etc
<DEL old 12>
12 Messaging on police cars
17 Other (specify)
18 - (DO NOT READ) Don't know (SKIPTO Q17)
19 - (DO NOT READ) Refused (SKIPTO Q17)
Q15b.
Have you read or seen anything on the internet about special effort
by police to ticket drivers for seat belt violations?
1 Yes
2 No
IF: (Q15B is Yes )
Was it an...
(READ LIST ---Multiple responses allowed)
(76.2) 01 News story
02 Internet ad
03 Internet game
04 Social Network message like FaceBook or Twitter
05 Internet video from something like You Tube
17 Other (SPECIFY)
IF: (Q15 is TV or Radio )
Q.16
Was the [Q15 message] a commercial (or advertisement), was it part of a
news program, or was it something else?
MULTIPLE RECORD
1 Commercial/Advertisement/Public Service Announcement
2 News story/news program
3 Something else (specify)
4 - (DO NOT READ) Don't know
5 - (DO NOT READ) Refused
IF: (Q15 is TV or Radio )
Q.16B
Did the [Q15 message] mention nighttime enforcement?
1 Yes
2 No
3 (DO NOT READ) Don't know
4 (DO NOT READ) Refused
Q17
Yes or No - in the past 30 days, have you seen or heard of anything about
the police setting up seat belt checkpoints where they will stop motor
vehicles to check whether drivers and passengers are wearing seat belts?
1 Yes
2 No (SKIPTO Q21)
3 (DO NOT READ) Don't know (SKIPTO Q21)
4 (DO NOT READ) Refused (SKIPTO Q21)
By checkpoint, we mean a systematic effort by police to stop vehicles for the purpose of checking for compliance with existing seat belt laws.
Q18
Let me just confirm, is this the type of checkpoint that you have seen or
heard about in the past 30 days?
1 Yes
2 No (SKIPTO Q21)
3 (DO NOT READ) Don't know (SKIPTO Q21)
4 (DO NOT READ) Refused (SKIPTO Q21)
Q19
Where did you see or hear about the police checkpoints for seat belts?
[DO NOT READ--MULTIPLE RESPONSE]
1 TV
2 Radio
3 Friend/Relative
4 Newspaper
5 Other
6 - (DO NOT READ) Don't know (SKIPTO Q21)
7 - (DO NOT READ) Refused (SKIPTO Q21)
IF: (Q19 is TV or Radio )
Q20
Was the [Q19 message] a commercial (or advertisement), was it part of a news
program, or was it something else?
MULTIPLE RECORD
1 Commercial / Advertisement/ Public Service Announcement
2 News story / news program
3 Something else (specify)
4 - (DO NOT READ) Don't Know
5 - (DO NOT READ) Refused
Q21
In the past 30 days, did you personally see any checkpoints where police were stopping motor vehicles to see if drivers and passengers were wearing seat belts?
1 Yes
2 No (SKIPTO Q24)
3 (DO NOT READ) Don't know (SKIPTO Q24)
4 (DO NOT READ) Refused (SKIPTO Q24)
Again, by checkpoint we mean a systematic effort by police to stop vehicles
for the purpose of checking for compliance with existing seat belt laws.
Q.22.
Let me just confirm, is this the type of checkpoint that you personally saw
in the past 30 days?
1 Yes
2 No (SKIPTO Q24)
3 (DO NOT READ) Don't know (SKIPTO Q24)
4 (DO NOT READ) Refused (SKIPTO Q24)
Q.23.
Were you personally stopped by police at a seat belt checkpoint in the past
30 days?
1 Yes
2 No
3 (DO NOT READ) Don't know
4 (DO NOT READ) Refused
Q24
In the past 30 days, have you seen or heard of any special effort by police
to ticket drivers in your community if children in their vehicles are not
wearing seat belts or are not in car seats or booster seats?
1 Yes
2 No
3 (DO NOT READ) Don't know
4 (DO NOT READ) Refused
Q25
Now, I would like to ask you a few questions about educational or other types of activities?
In the past 30 days, have you seen or heard any messages that encourage people to wear their seat belts. This could be public service announcements on TV, messages on the radio, signs on the road, news stories, or something else.
1 Yes
2 No (SKIPTO Q29)
3 (DO NOT READ) Don't know (SKIPTO Q29)
4 (DO NOT READ) Refused (SKIPTO Q29)
Q.26
Where did you see or hear these messages?
[DO NOT READ--MULTIPLE RESPONSE]
01 TV
02 Radio
03 Friend/Relative
04 Newspaper
05 Personal observation/on the road
07 Billboard/signs
08 Educational Program
09 I'm a police officer/judge
10 Direct contact by police officer
11 Internet/online/computer Game/email (not from friend)/social network/mobile phone internet/web etc
<DEL old 12>
12 Messaging on police cars
17 Other (specify)
18 - (DO NOT READ) Don't know (SKIPTO Q28)
19 - (DO NOT READ) Refused (SKIPTO Q28)
IF: (Q26 is Other (specify) )
(3855.1) PLEASE SPECIFY OTHER
(ENTER VERBATIM RESPONSE AND PRESS <ESC> TO CONTINUE)
GOTO Q28
IF: (Q26 is Other (specify) )
Q26b.
Have you read or seen anything on the internet that encourages people to wear their seat belts?
1 Yes
2 No
IF: (Q26B is Yes )
Was it an...
(READ LIST ---Multiple responses allowed)
01 News story
02 Internet ad
03 Internet game
04 Social Network message like FaceBook or Twitter
05 Internet video from something like You Tube
17 Other (SPECIFY)
IF: (Q26 is TV or Radio )
Q 27
Was the \:Q26 message a commercial (or advertisement), was it part of a
news program, or was it something else?
MULTIPLE RECORD
1 Commercial/Advertisement/Public Service Announcement
2 News story/news program
3 Something else (specify)
4 (DO NOT READ) Don't know
5 (DO NOT READ) Refused
Q.28
Would you say that the number of these messages you have seen or heard in
the past 30 days is more than usual, fewer than usual, or about the same as
usual?
1 More than usual
2 Fewer than usual
3 About the same
4 (DO NOT READ) Don't know
5 (DO NOT READ) Refused
Q.29
Are there any advertisements or activities that you have seen or heard in the past 30 days that encouraged adults to make sure that children use car seats or seat belts?
1 Yes
2 No (SKIPTO Q31)
3 (DO NOT READ) Don't know (SKIPTO Q31)
4 (DO NOT READ) Refused (SKIPTO Q31)
(3857.1) Q30
What did you see or hear?
Q31
Thinking about everything you have heard, how important do you think it is
for [State]to enforce seat belt laws for ADULTS more strictly...
very important, fairly important, just somewhat important, or not that
important?
1 Very important
2 Fairly important
3 Just somewhat important
4 Not that important
5 (DO NOT READ) Don't know
6 (DO NOT READ) Refused
Q32
Do you recall hearing or seeing the following slogans in the past 30 days?
READ LIST AND MULTIPLE RECORD YESES
01 Friends don't let friends drive drunk
02 Click it or ticket
03 Buckle Up America
04 Children In Back
05 You Drink and Drive. You Lose.
06 Didn't see it coming? No one ever does
07 Get the keys
08 Over the Limit under arrest
13 Click it or ticket
14 Buckle Up
36 Four Steps for Kids
37 BUCKLE UP IN YOUR TRUCK
41 You wouldn't treat a crash test dummy like a child
42 If they're under FOUR FEET, NINE INCHES, they need a booster seat
71 - (VOL) None of these
72 - (VOL) Don't know
73 - (VOL) Refused
Now, I need to ask you some basic information about you and your household.
Q.33
What is your age?
REFUSED=99
Q.34
Including yourself, how many persons, age 16 or older, are living in your
household at least half of the time or consider it their primary residence?
REFUSED=99
IF: (Q34 >= 2)
Q35
How many children age 15 or younger are living in your household at least half of the time or consider it their primary residence?
NONE=0 REFUSED=99
Q.36
Do you consider yourself to be Hispanic or Latino?
1 Yes
2 No
3 (VOL) Not sure
4 (VOL) Refused
Q.37
Which of the following racial categories describes you? You may select more
than one.
[READ LIST--MULTIPLE RECORD]
1 American Indian or Alaskan Native
2 Asian
3 Black or African American
4 Native Hawaiian or other Pacific Islander
5 White
6 (VOL)Other (Specify)
9 (VOL) Refused
Q.38
What is the highest grade or year of school you completed?
09 8th grade or less
10 9th grade
11 10th grade
12 11th grade
13 12th grade/GED
14 Some college
15 College graduate or higher
16 (VOL) Refused
Q.39
Do you have more than one telephone number in your household?
1 Yes
2 No (SKIPTO Q41)
3 (VOL) Don't know (SKIPTO Q41)
4 (VOL) Refused (SKIPTO Q41)
Q.40
Not including cells phones, and phones used primarily for fax or computer
lines, how many different telephone numbers do you have in your household?
10 OR MORE=10 DON'T KNOW=11 REFUSED=12
Q.41
FROM OBSERVATION, ENTER SEX OF RESPONDENT
1 Male
2 Female
NHTSA Form 1010
| File Type | application/msword |
| File Title | Q 10 |
| Author | jjurgaitis |
| Last Modified By | walter.culbreath |
| File Modified | 2011-05-02 |
| File Created | 2011-05-02 |