NHTSA Form 1304 Pre-Install Questionnaire

OMB Control No. 2127-XXXX

Expiration Date XX/XX/XXXX

Appendix F

Pre-Installation Questionnaire Form

This collection of information is voluntary and will be used to document demographics and crash risk perceptions of participants in the study. The results of the study will be used to develop programs designed to reduce the number of traffic-related injuries and deaths. 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. Public reporting for this collection of information is estimated to be approximately 5 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

Participant ID __________ Date_______________

Child Safety Seat Study: Pre-Install Questionnaire

(Self-administered)

Instructions for Item 1:

Please circle the number that best reflects your thoughts in response to Item 1 below.

Item 1:

I am likely to get in a crash in the next month when I am driving in the car by myself.

1	2	3	4	5
Strongly Disagree	Somewhat Disagree	Neutral	Somewhat Agree	Strongly Agree

FOR ITEMS 2 & 3, PLEASE RESPOND ONLY IF YOU HAVE CHILDREN OR ROUTINELY TRAVEL WITH CHILD PASSENGERS UNDER THE AGE OF 12.

Instructions for Item 2 and 3:

Again, please circle the number that best reflects your thoughts in response to the statements or questions below.

Item 2:

I am likely to get in a crash in the next month when I am driving the car and I am transporting child passengers (under the age of 12).

1	2	3	4	5
Strongly Disagree	Somewhat Disagree	Neutral	Somewhat Agree	Strongly Agree

Item 3:

If you were to get into a crash when driving with child passengers, how confident are you that the child passengers would be injury-free?

1	2	3	4	5
Not At All Confident	Somewhat Not Confident	Neutral	Somewhat Confident	Very Confident

2

NHTSA Form 1304