NHTSA Form 1065 Interview Form Refueling

United States Department of Transportation National Highway Traffic Safety Administration

INTERVIEW FORM REFUELING (5/26/10 Draft)

Form Approved O.M.B. No. 2127-0626 Expiration Date: XXXX National Automotive Sampling System Tire Pressure Monitoring System – Special Study

1. Primary Sampling Unit Number ____ ____

2. Site Number ____ ____

3. Observation Number ____ ____

4. Date of Observation ____ ____/____/2010

5. Interview in: O English O Spanish

6. Observations: ( O Interviewed O Refused O <2004)

   1. Body Type: Auto: O Small O Large

O SUV O Van O PU

2. Sex: O Male O Female

3. Age: O Young Adult O Adult O Senior

4. # in Vehicle: _____________ O Unknown

[Questions about Refueling]

7. Did you go out of your way to get to this gas station? If so, how far? ____________ (Nearest ¼ mile)

8. Did it take extra time to get to this gas station? If so, how long? ____________

(Code to nearest minute)

9. Before filling up your tank, where was the gas gauge? ________________ (Code to nearest 1/8^th tank)

10. How many persons total are in this vehicle? ______________________________________

11. How many of them are under the age of 16? _________________________________________

12. For each of the persons in this vehicle, what is his/her primary reason for traveling?

	Driver	Adults	<16 Yrs.
a. To/From Work
b. On Work Time
c. Other

13. How many gallons of gas did you put in your vehicle? ___________________ (Code to nearest gallon)

14. After adding gas to your tank, where was the gas gauge? _____________ (Code to nearest 1/8^th tank)

15. If Full: Do you always fill up your tank?

If refueling, skip to #16

O No O Yes

16. What is the primary reason you stopped for gas today? (Check one)

    1. O Gas tank low

    2. O Price of the gas

    3. O Fill up on routine basis (e.g., weekly, bi-weekly)

    4. O Top off tank for specific reason (e.g., before long trip)

    5. O Convenient at this time

    6. O To get/do something else (e.g., food, rest stop)

    7. O Other (specify) _________________

17. Does this vehicle have a Tire Pressure Monitoring System – also known as a TPMS system?

    1. O No

    2. O Yes

    3. O Don’t know

Now I need to ask you some basic information about yourself. [Demographic Information]

18. What is your home zip code? ___ ___ ___ ___ ___

19. How old are you? __________ (Code to nearest yr)

20. What is the highest grade or year of school you completed?

    1. O Less than high school

    2. O High school / GED

    3. O Some college

    4. O College graduate

    5. O Higher degree

    6. O (Vol) Refused

(Continue only for vehicles that have TPMS; Q#17)

21. Would you have time now to answer a few questions on TPMS?

    1. O No (Go to Q 22-Do Later)

    2. O Yes (Go to Supplemental Form)

22. Would you be willing to answer a few questions on TPMS at a later date, using:

    1. O On-line

    2. O Mail-back form

    3. O Phone call back

    4. O Refuse (End)

23. What is your name? ___________________________

24. At what phone number(s) would you like to be called? _______________________________________

25. What are good times to call? ___________________

26. SUP ID: _______________________

***Note: Check that INR13-INR15 have been answered***