Mock Crash Survey – Sample – Chesapeake Region Safety Council

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Home / Mock Crash Survey – Sample

Mock Crash Survey

School Name (Mock Crash Survey)

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Grade *

Date *

a Did up?

Driver’s License Status *

Learner’s Permit
Provisional Driver’s License (under 18)
Full Driver’s License (18 or older)
I am Unlicensed

In the last 30 days have you:

Impairment

Consumed alcohol or used cannabis within 4 hours of driving? *

Very Often
Often
Not Often
Not At All

Ridden in another young driver’s vehicle after they had consumed alcohol or cannabis in the previous 4 hours? *

Very Often
Often
Not Often
Not At All

Occupant Protection

Driven/ridden as a passenger in any seating position without wearing a seat belt? *

Very Often
Often
Not Often
Not At All

Operated a vehicle with unbuckled passengers? *

Very Often
Often
Not Often
Not At All

Requested that someone else in a vehicle buckle up? *

Very Often
Often
Not Often
Not At All

Fatigue

Driven while so tired that you had a hard time keeping your eyes open? *

Very Often
Often
Not Often
Not At All

Asked for someone else to drive as you didn’t feel up to it due to stress, tiredness, or disinterest *

Very Often
Often
Not Often
Not At All

Drove because you had to – even though you didn’t feel you were up to it mentally or physically *

Very Often
Often
Not Often
Not At All

Distracted

Read or typed a message (through any platform) or e-mail while operating a moving vehicle? *

Very Often
Often
Not Often
Not At All

Used a social media app while operating a moving vehicle? *

Very Often
Often
Not Often
Not At All

Talked on a cell phone without a hands-free device used while operating a moving vehicle? *

Very Often
Often
Not Often
Not At All

Drove out of your lane onto the shoulder or grass due to inattention *

Very Often
Often
Not Often
Not At All

Distracted someone from being able to pay full time and attention while they were operating a moving vehicle? *

Very Often
Often
Not Often
Not At All

Forgot to slow down and/or move over as required in a work zone? *

Very Often
Often
Not Often
Not At All

Drove poorly as a result of being irritated or upset by something else that had occurred during my day? *

Very Often
Often
Not Often
Not At All

General

Felt proud of yourself after handling a challenging drive? *

Very Often
Often
Not Often
Not At All

Ridden in another driver’s vehicle and felt their driving was unsafe? *

Very Often
Often
Not Often
Not At All

Driven 20 MPH or more over the posted speed limit? *

Very Often
Often
Not Often
Not At All

Had to deal with driving in poor weather conditions you were unprepared for? *

Very Often
Often
Not Often
Not At All

Asked another driver to change how they were driving due to feeling unsafe? *

Very Often
Often
Not Often
Not At All

Driven and ignored a vehicle dashboard warning light or a maintenance issue that should have been addressed? *

Very Often
Often
Not Often
Not At All

Did not know how to manage your vehicle’s roadway positioning when emergency responders were approaching? *

Very Often
Often
Not Often
Not At All

Had an emergency alert notification show up on your phone or vehicle infotainment system about an approaching emergency vehicle, disabled vehicle or other emergency ahead. *

Very Often
Often
Not Often
Not At All

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2555 Lord Baltimore Dr
Suites M-R
Baltimore, MD 21244
800-875-4770
safety@chesapeakesc.org

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