Form NHTSA Form 1217 NHTSA Form 1217 Student Survey

Appendix C-1: Student Survey

Expiration Date xx/xx/xxxx

OMB Control No. 2127-XXXX

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to 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 respondent, 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, SE, Washington, DC 20590.

274 Child Interview/Survey Questions

Observe—Do NOT Ask

Interviewer______________ School_________________

Date___________ Grade: K 1 2 3 4 5 Section _________________

Gender: M F Race: W B A AI/AN HN/PI 2+

Hispanic: Y N ?

Read to Student

Hi, my name is [First Name Only]. I’m going to ask you a few questions. You can either answer or show me what you would do. Is that okay with you? (If answer is no, Do not continue—take child back to class)

1. Pretend you’re on a sidewalk with no parked cars and you want to cross the street. There is no one around to help you cross. What should you do before crossing the street to be safe?

   1.  Go to corner

   2.  Stop at curb

   3.  Wait for light

   4.  Look for cars (ask to show how and check one)

      1.  Look L

      2.  Look R

      3.  Look R-L

      4.  Look L-R

      5.  Look L-R-L

      6.  Look R-L-R

   5.  Wait for adult

   6.  Nothing

   7.  Don’t know

   8.  Other_______________________

2. Pretend you’re on a sidewalk with parked cars near where you want to cross the street. What should you do before crossing the street to be safe?

   1.  Go to corner

   2.  Stop at curb

   3.  Wait for light

   4.  Stop outside edge of parked cars

   5.  Look for cars (ask to show how and check one)

      1.  Look L

      2.  Look R

      3.  Look R-L

      4.  Look L-R

      5.  Look L-R-L

      6.  Look R-L-R

   6.  Wait for adult/I can’t cross without an adult

   7.  Nothing

   8.  Don’t know

   9.  Other_______________________

3. You want to cross the street and you’ve stopped to look for cars that might be coming. While you’re looking, you see a car coming close. What should you do before crossing the street to be safe?

   1.  Let the car pass

   2.  Look for cars all over again (ask to show how and check one)

      1.  Look L

      2.  Look R

      3.  Look R-L

      4.  Look L-R

      5.  Look L-R-L

      6.  Look R-L-R

   3.  Other_______________________

   4.  Nothing

   5.  Don’t know

4. Please show me your left hand.

   1.  Correct response

   2.  Incorrect response

   3.  No response

5. Where is it safe to cross a street?

   1.  Any mention of sidewalk

   2.  Any mention of crosswalk

   3.  Any mention of crossing guard

   4.  With parent or other adult

   5.  Can see clearly in both directions

   6.  No visual barriers/screens

   7.  Any mention of traffic lights

   8.  Any mention of pedestrian signal

   9.  No cars coming

   10.  Any mention of walking in a group

   11.  Any mention of road geometry (e.g., 2-lane roads, narrow streets)

   12.  Other____________________

6. True or False: When you are walking with an adult, you don’t have to watch out for traffic.

   1.  True

   2.  False

   3.  Don’t know

7. What is the danger zone near a school bus?

   1.  Correct

   2.  Incorrect

   3.  Don’t know

8. True or False: Drivers backing up in parking lots can always see you because they have mirrors on their cars.

   1.  True

   2.  False

   3.  Don’t know

9. Has anyone at home helped you learn about walking safely near traffic?

   1.  Yes

   2.  No

1. If yes, who?

   1.  Mother

   2.  Father

   3.  Grandparent

   4.  Sibling

   5.  Other family

   6.  Other adult

2. If yes, what have they done with you?

   1.  Homework assignments

   2.  Taught left-right-left

   3.  Showed me where to cross the street

   4.  Taught me [how to read][the meaning of] traffic/pedestrian signals

   5.  Yelled at me to be safe

   6.  Told me to stay out of street/be safe

   7.  Other ________________________________

10. Were there any classes at school this year about walking safely near traffic?

    1.  Yes

    2.  No

    3.  Don’t know/Don’t remember/Not sure

If yes,

1. Were they fun?

   1.  Yes

   2.  No

   3.  Don’t know/Don’t remember/Not sure

2. Did you learn anything?

   1.  Yes

   2.  No

   3.  Don’t know/Don’t remember/Not sure

NHTSA Form 1217 Page 1