Evaluation of Female Driver Responses
to Impaired Driving Messages
Final Report -- December 2000
LOCATION___________________________
DATE_____________
Participant Information Form
Please complete this form before the focus group starts. The information you provide will be used only to summarize the characteristics of the group. The data collected will remain confidential. Your name and address are not needed.
1. What is your age? _____
2. Are you employed outside the home?
___ No
___ Yes
IF YES, do you work
___ full time
___ part timeIF YES, what is your occupation? ______________________________________
3. The highest education I completed was:
___ Elementary school
___ Junior high / middle school
___ High school or GED
___ Technical / vocational school
___ Community college (2 years)
___ University (4 years)
___ Graduate school
___ Attending School now, Grade/Year___________
4. My family's yearly income is:
___ Below $15,000
___ $15,001 to $30,000
___ $30,001 to $50,000
___ $50,001 to $75,000
___ Above $75,000
5. What is your marital status?
___ Married
___ Living with boyfriend/partner
___ Single, never married
___ Separated
___ Divorced
___ Other, please specify____________________
6. Where do you live?
___ In the city
___ In a suburb
___ In a housing area that is not in a city or town
___ In a rural area
7. Do you consider yourself to be:
___ African-American / Black
___ Hispanic / Latino
___ Asian / Pacific Islander
___ White
___ Mixed Race
___ Other, please specify ________________
8. What are the ages of any children who live with you?____________________
N/A_________
9. When do you do most of your driving?
___ Morning / evening rush hour
___ Other daytime
___ Night
10. How would you describe the traffic you drive in most often?
___ Light
___ Light to medium
___ Medium to heavy
___ Heavy
11. Would you say that you take more risks than the average driver, take typical risks, or that you are more cautious than the typical driver?
___ Take more risks
___ Typical
___ More cautious
12. How often do you wear a seatbelt when you drive?
___ Always
___ Most of the time
___ Sometimes
___ Never
13. How often do you drive more than 15 miles per hour above the posted speed?
___ Very often
___ Seldom
___ Occasionally
___ Never
14. How often do you drink alcoholic beverages?
___ Seldom drink
___ Drink a few times a month
___ Drink a few times a week
___ Drink almost every day
___ Other, please specify ________________
15. Which of the following best describes your usual drinking pattern? (check only one)
___ Only at parties and social gatherings
___ Only drink with meals
___ Drink at bars
___ Drink at home with family and friends
___ Drink alone, at home or bars
___ Other, please specify ________________
16. How often do you drive within an hour of having one or more alcoholic drinks?
___ Very often
___ Occasionally
___ Seldom
___ Never
17. Have you been stopped or ticketed for a traffic violation in the past 3 years?
___ No
___ Yes
IF YES, for what?_____________________________
18. Have you ever been ticketed for drinking and driving?
___ Yes
___ No
PLEASE RETURN THE COMPLETED FORM
TO THE FOCUS GROUP MODERATOR BEFORE WE START.
THANK YOU FOR YOUR HELP!
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