SAMPLE - DRIVER LICENSING OFFICE SURVEY

This driver licensing office is assisting in a study about safety belts in North Carolina.  Your answers to the following questions are voluntary and anonymous.  Please complete the survey and then put it in the drop box.

1.   Your sex:          Male       Female             

2.   Your age:         Under 21    21-25     26-39      40-49          50-59          60 Plus

3.   Your race:    White      Black       Asian          Native American            Other              

4.   Are you of Spanish/Hispanic origin?        Yes       No

5.   Your Zip Code:  _______________________

6.   About how many miles did you drive last year?

            Less than 5,000        5,000 to 10,000        10,001 to 15,000           More than 15,000

7.   What type of vehicle do you drive most often?

       Passenger car           Pickup truck            Sport utility vehicle        Mini-van          Full-van       

8.   How often do you use safety belts when you drive or ride in a car, van, sport utility vehicle or pick up?

            Always                       Nearly always                     Sometimes                Seldom             Never

9.   What do you think the chances are of getting a ticket if you don't wear your safety belt?

             Always                        Nearly Always                  Sometimes        Seldom         Never

10.   Do you think the North Carolina Highway Patrol enforce the safety belt law:

             Very strictly                Somewhat strictly             Not very strictly    Rarely               Not at all

11.   Do you think local police enforce the safety belt law:

             Very strictly         Somewhat strictly               Not very strictly   Rarely                Not at all

12.   Have you ever received a ticket for not wearing your safety belt?      

             Yes            No

13.   In the past month, have you seen or heard about a checkpoint where police were looking at
safety belt use?

             Yes            No

14.   In the past month, have you gone through a checkpoint where police were looking at safety belt use?

             Yes            No

15.   Have you recently read, seen or heard anything about safety belts in North Carolina?

 Yes            No

          If yes, where did you see or hear about it? (Check all that apply):

           Newspaper        Radio        TV        Poster        Brochure        Police checkpoint        Other

                     If yes, what did it say? ___________________________________________________________   

16.   Do you know the name of any safety belt enforcement program(s) in North Carolina? (check all that apply):

 No Excuses, Buckle Up      Buckle Up North Carolina            Click It or Ticket            Operation Stay Alive