Form Approved: University of Maryland Baltimore Institutional Review Board
IRB #: HM-HP-00051544-1
Expiration Date: 7/2/15

1. What is today's date?

Date
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2. What was the name of the program you attended or where did you get this survey?

3. Indicate the COUNTY where you LIVE:

4. What is your HOME zip code?

5. What is your AGE?

6. What is your SEX?

7. Are you Hispanic or Latino?

8. Select one or more of the following:

9. Indicate your WEEKLY driving mileage (car/van/SUV/pick-up):

10. Indicate your level of agreement:

  Strongly Agree Somewhat Agree Somewhat Disagree Strongly Disagree Undecided
I often act on the spur of the moment.
I like to drive more than 10 MPH over the posted speed limit.
Most of my family and friends think it's ok to talk on a cell phone without using a hands-free device while driving.
Most of my family and friends think that it is ok to text while driving.
I am likely to text the next time I drive.
I am likely to talk on a cell phone without using a hands free device the next time I drive.
Most of my family and friends routinely drive at least 10 MPH over the posted speed limit.
In the past 30 days, I have driven more than 10 MPH over the posted speed limit.
If I am stopped for drinking and driving, the punishment will be severe.
I am likely to be stopped by police if I drive more than 10 MPH over the speed limit

11. Indicate the likeliness of each:

  Very Likely Somewhat Likely Not Very Likely Not Likely Don't Know
How likely is it that something bad would happen if you don't wear your seat belt?
How likely are you, as a PEDESTRIAN, to be stopped for a cross walk violation?
How likely are you to be stopped by police if you drive within two hours of drinking alcoholic beverages?
How likely are you to get a ticket if you don't wear your seat belt?
How likely are you, WHILE DRIVING A MOTOR VEHICLE, to be stopped for a crosswalk/pedestrian violation?

12. Indicate how often:

  5 or More Times 3-4 Times 1-2 Times Never
During the past 30 days, how many times did you RIDE in a car or other vehicle driven by someone who had been drinking alcoholic beverages?
In the past week, how often have you used your cell phone without a hands-free device while driving?
In the past 30 days, how many times have YOU DRIVEN a car or other vehicle within 2 hours of drinking alcoholic beverages?
In the past week, how often have you texted while driving?

13. Think of the last time you did not use a crosswalk - what was your reason for not using the crosswalk? (Mark all that apply)

14. Indicate how often:

  All of the time Most of the time Occasionally Rarely Never
How often do you use a seat belt when you drive or ride in the FRONT seat of a car, van, SUV or pick-up truck?
When driving with child passenger(s) under 13 years, how often do you make them sit in a back seat?
How often do you use a seat belt when you ride in a BACK seat of a car, van, SUV or pick-up truck?

15. Do you transport children under the age of 10 in a car, van, sports utility, or pick-up truck?

16. Indicate which COUNTY you were when you TOOK this survey.

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