NHTSA Form 1216 Caregiver Survey - English

Appendix C-2: Caregiver Survey - English

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, 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 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.

[School Name] is participating in an important research study. Your answers to the following questions are an important part of the study and are voluntary and anonymous. Please complete the survey for each student who brought it home and put it back in their homework folder to be returned to the school. Thank you!

What is your gender?  Male  Female

What is your age?  Under 21  21-34  35-49  50-59  60 plus

What is your race?  White  Black/African American  American Indian or Alaska Native  Asian

 Hawaiian Native or Pacific Islander  ____________

Are you of Hispanic or Latino origin?  Yes  No

How are you related to the student who brought this survey home?

 Parent  Grandparent  Sibling  Other relative  Other caregiver

How good is this child’s knowledge of the rules for walking safely near traffic?

 Very poor  Poor  Fair  Good  Very good

Could this child safely cross the street alone?

 Yes  Yes, but I would not allow it  No

How important is it for children of this age to be taught to walk safely near traffic?

 Not important  Slightly important  Moderately important  Very important

How much information do children have to be taught in order to learn to walk safely near traffic?

 Nothing  Very little  A bit  Quite a lot  A lot

Check all the places where you have heard or seen anything about child pedestrian safety in the last 3 months?

 TV  Radio  Newspaper  Internet  Child’s homework  Police  Tip Sheet from school

 School meeting  Other meeting  Other_______________________  Have not seen/heard anything

In the past 3 months, has this child talked about walking safely near traffic?

 Yes  No  Not sure/Don’t Know

Is how to walk safely near traffic taught at this child’s school?

 Yes  No  Not sure/Don’t Know

In the past 3 months, how much time have you spent working with this child on how to walk safely near traffic?

 None  Less than 1 hour  1-2 hours  More than 2 hours

In the past 3 months, have you noticed any improvement in the way this child walks near traffic?

 Yes  No  Not sure/Don’t know

If yes, what improvements?_______________________________________________________________________

In the past 3 months, have you learned anything new about walking safely near traffic?

 Yes  No  Not sure/Don’t know

If yes, what have you learned?_____________________________________________________________________

In the past 3 months, how often has this child walked to or from school?

 Never  Rarely  Occasionally  Frequently  Almost always

Which of the following is most important for improving pedestrian safety in Wilson County? (Select one)

 More sidewalks  More/better crosswalks  Police enforcement  More education for pedestrians

 Slower speeds  Better lighting  Other _________________________

NHTSA Form 1216 Page 3