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What is your gender?
 
Male
 
Female
 
 
 
What is your age?
 
13
 
14
 
15
 
16
 
17
 
18+
 
 
 
What grade are you in?
 
9th
 
10th
 
11th
 
12th
 
 
 
Do you wear a seatbelt?
 
Yes
 
No
 
 
 
What is your license status?
 
License
 
Permit
 
Neither
 
 
 
How would you consider your driving ability?
 
N/A
 
Poor
 
Below Average
 
Average
 
Above Average
 
Excellent
 
 
 
Have you ever been in an accident while driving?
 
Yes
 
No
 
I don't drive
 
 
 
If so, who was at fault?
 
I have never been in an accident
 
Yourself
 
Other Party
 
Mutual
 
 
 
Have you ever done any of the following while driving?
 
Recklessly drove
 
Illegally drove passengers
 
Talked on the phone
 
Texted
 
Driven under the influence of alcohol or other drugs
 
I have never done any of the above things.

 
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