NHTSA 1108 ATT C4 NCRUSS Interview-Restraints

ATTACHMENT C4

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 2127-0642. Public reporting for this collection of information is estimated to be approximately 7 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. NHTSA Form 1 108

United States Department of Transportation National Highway Traffic Safety Administration	INTERVIEW FORM RESTRAINTS (3/10/11 Draft)					Form Approved O.M.B. No. 2127-0642 Expiration Date: xxxx National Automotive Sampling System National Child Restraint Use – Special Study
Primary Sampling Unit Number: _____ _____		Site Number: _____ _____
Observation Number: _______/_______		Date of Observation: _______/_______/2011
(Circle for Only One Child--the child being observed) __ 12 13 (1st row: ___, middle, right) 21 22 23 (2nd row: left; middle, right) 31 32 33 (3rd row: left; middle, right) Other _______________________________ For the child safety seat or booster in SP ___: What is the make of this seat? ______________ What is the model? 1 __________________________ 2 O DK 3 O Refused 4 O DA		O Baby Trend O Britax O Chicco O Combi O Cosco O Cybex O Dorel O Eddie Bauer O Evenflo			O Graco O Maxi Cosi O Learning Curve-1st Yrs. O Magna/Clek O Mia Moda O Orbit O Peg Perego O Recaro			O Safety 1st O Safe Traffic Systems O Summer O Sunshine Kids O DK O Refused O DA O Other __________________
How long have you had this seat?		1 Yrs _________ 2 Months _______ 3 O DK 4O Refused 5 O DA
Did you get it new or used?		1 O New 2 O Used 3 O DK 4 O Refused 5 O DA
Did you read the instructions for installing this SEAT that came......? (Read, randomizing order; Select all that apply)		On the box for the car seat On the label of the car seat In the owner’s manual for the car seat In the owner’s manual for the vehicle O DK, Ref, or DA (Circle one)
Has this seat been checked or inspected at a seat check or by a certified passenger safety technician (CPST)? (If 2, 3, 4, or 5 answered, Skip to Q14)		1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA
How long ago was it (last) checked? (If 3, 4, or 5 answered, Skip to Q14)		1 Yrs _________ 2 Months _______ 3 O DK 4O Refused 5 O DA
Has it been moved since it was (last) checked?		1 O Yes 2 O No (Skip to Q15) 3 O DK 4 O Refused 5 O DA
For how long has this seat (and its base) been installed in the current SP without being uninstalled or moved?		1 Yrs _________ 2 Months _______ 3 Days ______ (If Yrs & Mon = 0) 4 O DK 5 O Refused 6 O DA
On a scale from 1 to 5 with 1= Not Confident & 5= Very Confident, how confident are you that it was installed correctly?		1 Scale: 1-------2-------3------4------5 2 O DK 3 O Refused 4 O DA (Not Confident) (Very Confident)
Today, who put this child in his/her seat?		1 O Self 2 O Joint w/other 3 O Partner/spouse/significant other 4 O Parent or other family member 5 O Friend or neighbor 5 O Child 6 O CPST 7 O DK 8 O Refused 9 O DA 10 O Other __________________________________________
FOR BELT POSITIONING BOOSTER SEATS, SKIP TO Q46; OTHERWISE CONTINUE
Some seats have a strap on the back of the seat near the top called a tether. Does your seat have a tether strap?			1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA
For SP _____, does your vehicle have a place to hook the seat top tether strap? (If “no” to either Q16 or Q17, Skip to Q25)			1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA
Are you using the tether?			1 O Yes (Skip to Q21) 2 O No 3 O DK 4 O Refused 5 O DA
(If no) What is the main reason that you are not using the tether? (Skip to Q25)			1 O DK about it 2 O Didn’t think it was important 3 O DK how to use it 4 O Too hard to use 5 O RF seat 6 O Over weight limit 7 O Can’t find 8 O Refused 9 O DA 10 O Other: __________________
(If yes) What is the main reason that you are using the tether?			1 O Law 2 O Safer 3 O Instructions 4 O DK 5 O Refused 6 O DA 7 O Other: __________________
Who attached the tether? (If any item from 3-10 is answered, Skip to Q25 )			1 O Self 2 O Joint w/other 3 O Partner/spouse/significant other 4 O Parent or other family member 5 O Friend or neighbor 6 O CPST 7 O DK 8 O Refused 9 O DA 10 O Other _________
On a scale from 1 to 5 with 1= Very Difficult & 5= Very Easy, how difficult or easy did you find it to: Attach the tether? Get a tight fit?			1---------2---------3--------4--------5 (Very Difficult) (Very Easy) 1--1 O Scale #: ____________ 2 O DK 3 O Refused 4 O DA 2--1 O Scale #: ____________ 2 O DK 3 O Refused 4 O DA
Have you ever disconnected this tether? (If any item from 2-5, Skip to Q25)			1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA
On a scale from 1 to 5 with 1= Very Difficult & 5= Very Easy, how difficult or easy did you find it to disconnect the tether?			1 O Scale #: _______________ 2 O DK 3 O Refused 4 O DA
Some seats have 2 straps/attachments on the bottom called lower anchor straps/attachments. Does this seat have lower straps/attachments to connect or hook it to the vehicle?			1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA
For SP ___, does your vehicle have lower anchors? (If “no” to either Q25 or Q26, Skip to Q36 )			1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA
Are you using the lower straps/attachments with the lower anchors?			1 O Yes (Skip to Q30) 2 O No 3 O DK 4 O Refused 5 O DA
(If no) What is the main reason that you are not using the lower straps/attachments with the lower anchors? (Skip to Q36)			1 O DK about it 2 O Didn’t think it was important 3 O DK how to use it 4 O Too hard to use 5 O RF seat 6 O Over weight limit 7 O Can’t find 8 O Refused 9 O DA 10 O Other: __________________
(If yes) ) What is the main reason that you are using them?			1 O Law 2 O Safer 3 O Instructions 4 O DK 5 O Refused 6 O DA 7 O Other: __________________
Who installed the seat with the lower anchors? (If any item from 3-10 is answered, Skip to Q34 )			1 O Self 2 O Joint w/other 3 O Partner/spouse/significant other 4 O Parent or other family member 5 O Friend or neighbor 6 O CPST 7 O DK 8 O Refused 9 O DA 10 O Other _________
On a scale from 1 to 5 with 1= Very Difficult & 5= Very Easy, how difficult or easy did you find it to: Install this seat using the lower anchors? Get a tight fit?			1---------2---------3--------4--------5 (Very Difficult) (Very Easy) 1--1 O Scale #: ___________ 2 O DK 3 O Refused 4 O DA 2--1 O Scale #: ___________ 2 O DK 3 O Refused 4 O DA
Have you ever uninstalled this seat after it had been installed with lower anchors)? (If any item from 2-5, Skip to Q34)			1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA
On a scale from 1 to 5 with 1= Very Difficult & 5= Very Easy, how difficult or easy did you find it to unInstall the seat (when using the lower anchors)?			1 O Scale #: ___________ 2 O DK 3 O Refused 4 O DA
Are you also using the safety belt to attach the seat?			1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA (If 2-5, Skip to Q44)
What is the main reason that you use both (i.e., SB and the lower anchors)? (Skip to Q39)			1 O Extra secureness or safety 2 O Believed it was necessary 3 O DK 4 O Refused 5 O DA 5 O Other: _________
Are you using the SB to attach the seat to the vehicle?			1 O Yes (Skip to Q39) 2 O No 3 O DK 4 O Refused 5 O DA
(If no) ) What is the main reason that you are not using the SB? (Skip to Q42)			1 O DK about it 2 O Didn’t think it was important 3 O DK how to use it 4 O Too hard to use 5 O RF seat 6 O Over weight limit 7 O Can’t find 8 O Refused 9 O DA 10 O Other: __________________
(If yes) ) What is the main reason that you are using the SB?			1 O Law 2 O Safer 3 O Instructions 4 O DK 5 O Refused 6 O DA 7 O Other: __________________
Who installed the seat with the SB? (If any item from 3-10 is answered, Skip to Q43 )			1 O Self 2 O Joint w/other 3 O Partner/spouse/significant other 4 O Parent or other family member 5 O Friend or neighbor 6 O CPST 7 O DK 8 O Refused 9 O DA 10 O Other _________
On a scale from 1 to 5 with 1= Very Difficult & 5= Very Easy, how difficult or easy did you find it to: Install this seat using the seat belt? Get a tight fit?			1---------2---------3--------4--------5 (Very Difficult) (Very Easy) 1--1 O Scale #: ___________ 2 O DK 3 O Refused 4 O DA 2--1 O Scale #: ___________ 2 O DK 3 O Refused 4 O DA
Have you ever uninstalled this seat after it had been installed with the seat belt? (If any item from 2-5, Skip to Q43)			1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA
On a scale from 1 to 5 with 1= Very Difficult & 5= Very Easy, how difficult or easy did you find it to unInstall the seat when using the seat belt? :			1 O Scale #: ___________ 2 O DK 3 O Refused 4 O DA
Have you ever used any of the following with this or another child safety seat in this vehicle? (IF “NO” TO Q43.2 OR Q43.3, SKIP TO Q47)			1. Tether Anchor? 1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA 2. Lower Anchors (LA)? 1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA 3. Seat Belt (SB) 1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA
Do you prefer LA or SB?			1 O LA 2 O SB 3 O Undecided 4 O DK 5 O Refused 6 O DA
Is it easier to attach a seat to the vehicle with the lower anchors or vehicle safety belt?			1 O LA 2 O SB 3 O Undecided 4 O DK 5 O Refused 6 O DA
If you have ever driven somewhere when a child in the vehicle was not secured in a child safety seat or booster, describe the primary reason			1 O Never have 2 O Short trip 3 O Child unbuckled self 4 O No seat/booster in vehicle 5 O Forgot to check 6 O Too many passengers in the vehicle 7 O Child does not cooperate 8 O Don't know 9 O Refused 10 O DA 11 O Other ________________
Gender (Do by Observation)			1 O Male 2 O Female
Are you of Hispanic or Latino origin?			1 O Yes 2 O No 3 O DK 4 O Refused 5 O DA
Which of the following best describes your race? (Select all that apply)			1 O White 2 O Black or African American 3 O Asian 4 O Native Hawaiian/Other Pacific Islander 5 O American Indian/Alaska Native 6 O Refused 7 O DA 8 O Other: ___________________________
Do you mind telling me your age?			1 O Don’t Mind: _____________ (Years) 2 O Do Mind
(Skip if Q50 answered) Would you prefer to point to your age range?			1 O 13-19 2 O 20-29	3 O 30-39 4 O 40-49			5 O 50-59 6 O 60-69		7 O 70-79 8 O 80+	9 O DK 10 O Refused 11 O DA
Interview completed: 1 O Yes 2 O No			Time Completed: ______________________