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FHWA Highway Safety Programs

Appendix Screening Form (English)


FHWA/NHTSA Hispanic Pedestrian and Bicycle Safety



Name: _______________________________________________

Street Address: ________________________________________________

City: _____________________________ State: ________ Zip: __________

Telephone Number (Home): ____________________ (Work): _________________

Inclusion Criteria:

  • Male; Female
  • Hispanic/Latino
  • Over the age of 18, mix of ages, at least one person per group over age 60
  • Any education level; any income level
  • Walks a half mile or more two or more times per week, or bicycles once or more per week
  • Spanish-speaking

Hello, my name is ___________ and I'm calling on behalf of a company that is doing research on traffic safety. I want to assure you, we are not selling anything, and your answers are completely confidential. We are doing focus groups in your area on ___________ [DC: March 30, NY: April 1, MIA: April 5, LA: April 8], and participants in the focus groups will earn $75 for their time. Do you have a few minutes to answer some brief questions to find out if you are eligible to participate?


INDICATE GENDER: (Female) (Male)

I'd like to start by asking you some questions about your background:

  1. May I ask your age? _____
    • ( ) Under 18 [SKIP TO CLOSE]
    • ( ) 18-29 [CONTINUE]
    • ( ) 30-39 [CONTINUE]
    • ( ) 40-49 [CONTINUE]
    • ( ) 50-59 [CONTINUE]
    • ( ) 60-69 [CONTINUE]
    • ( ) 70-79 [CONTINUE]
    • ( ) 80 or older [CONTINUE]

    [Need at least one person over age 60 in each group, ideally 2 per group]

  2. Would you describe yourself as:
    • ( ) Hispanic or Latino [CONTINUE]
    • ( ) White, not of Hispanic origin [SKIP TO CLOSE]
    • ( ) Black, not of Hispanic origin [SKIP TO CLOSE]
    • ( ) Asian [SKIP TO CLOSE]
    • ( ) Native Hawaiian or other Pacific Islander [SKIP TO CLOSE]
    • ( ) American Indian or Alaskan Native [SKIP TO CLOSE]
    • ( ) Other [SKIP TO CLOSE]
  3. How often do you speak Spanish at home? Would you say you speak Spanish:
    • ( ) All of the time [CONTINUE]
    • ( ) More than half the time [CONTINUE]
    • ( ) Some of the time [CONTINUE]
    • ( ) Rarely [SKIP TO CLOSE]
  4. Can you tell me where you were born in? (Recruit a mix of U.S. and non-U.S. born, with more born outside than inside the U.S.):
    • ( ) The United States [CONTINUE]
    • ( ) Mexico [CONTINUE]
    • ( ) Puerto Rico [CONTINUE]
    • ( ) Cuba [CONTINUE]
    • ( ) Central America [CONTINUE]
    • ( ) South America [CONTINUE]
    • ( ) Other [CONTINUE]
  5. What is the highest level of education you have completed?
    • ( ) Less than high school graduate [CONTINUE]
    • ( ) High school graduate/GED [CONTINUE]
    • ( ) Some college [CONTINUE]
    • ( ) College degree [CONTINUE]
    • ( ) Graduate or professional degree [CONTINUE]
  6. Could you please give me an estimate of your annual household income? Would you say it is:
    • ( ) Less than $15,000 per year [CONTINUE]
    • ( ) Between $15,000-$25,000 per year [CONTINUE]
    • ( ) Between $25,000-$40,000 per year [CONTINUE]
    • ( ) Between $40,000-$60,000 per year [CONTINUE]
    • ( ) More than $60,000 per year [CONTINUE]
  7. In a typical week, how often do you ride a bicycle in an urban area? For example, biking to the grocery store, biking from your home to the bus stop, or biking to work.
    • ( ) Never [CONTINUE]
    • ( ) Once [INVITE BIKE]
    • ( ) More than once [INVITE BIKE]
  8. In a typical week, how many days do you walk a half mile or more outdoors, that is, about ten or more minutes continuously? For example, walking to the grocery store, walking to the bus stop, or walking to work.
    • ( ) Never [SKIP TO CLOSE]
    • ( ) One day [SKIP TO CLOSE]
    • ( ) Two to three days [INVITE WALK]
    • ( ) Four to five days [INVITE WALK]
    • ( ) Six to seven days [INVITE WALK]


Thank you for answering our questions. As I said earlier, we are conducting research on traffic safety.

We would like to invite you to participate in a small group discussion on


  • DC: March 30, 5-7 pm
  • NY: April 1, 7:30-9:30 pm
  • MIA: April 5, 5-7 pm
  • LA: April 8, 7:30-9:30 pm


  • DC: March 30, 7:30-9:30 pm
  • NY: April 1, 5:00-7:00 pm
  • MIA: April 5, 7:30-9:30 pm
  • LA: April 8, 5:00-7:00 pm

consisting of about 8 other people like yourself and a moderator. The session will be conducted in Spanish. This is not a sales meeting. No one will try to sell you anything; we are only interested in your opinions. Your thoughts will help us better understand people's attitudes about traffic safety. The discussion will last about two hours, and we will give you $75 for your participation.

Would you be willing to participate in such a discussion?

  • (Yes) [Continue INVITATION] (No) [SKIP TO CLOSE]

Great! In the next few days, we will send you a packet of information that includes directions to the facility as well as a reminder about the date and time of the discussion. If you can't attend this meeting, will you please call us at 1-800-565-4352/301-565-0770 so that we can find someone to replace you? [Wait for answer]

May I verify the correct spelling of your name, as well as your correct address and phone number so that we may send you the confirmation letter? [Refer to the top of the page]

We'll also call you the night before the discussion to remind you about this group. It is very important that you arrive on time. Thank you very much for accepting our invitation. We look forward to hearing your thoughts and opinions. Have a nice day.


Thank you for taking the time to talk to us. I'm sorry, but you will not be eligible to participate in our study. We will call you again if we have another opportunity in your area. Have a nice day.