Appendix A to Part 1340 - State Seat Belt Use Survey Reporting Form

Appendix A to Part 1340 - State Seat Belt Use Survey Reporting Form

PART A: To be completed by the Governor's Highway Safety Representative (GR) or if applicable, the Coordinator of the State Highway Safety Office.

State:

Calendar Year of Survey:

Statewide Seat Belt Use Rate:

I hereby certify that:

• ________________has been designated by the Governor as the State's Highway Safety Representative (GR), and if applicable, the GR has delegated the authority to sign the certification in writing to __________________, the Coordinator of the State Highway Safety Office.

• The reported Statewide seat belt use rate is based on a survey design that was approved by NHTSA, in writing, as conforming to the Uniform Criteria for State Observational Surveys of Seat Belt Use, 23 CFR Part 1340.

• The survey design has remained unchanged since the survey was approved by NHTSA.

• ________________, a qualified survey statistician, has reviewed the seat belt use rate reported above and information reported in Part B and has determined that they meet the Uniform Criteria for State Observational Surveys of Seat Belt Use, 23 CFR Part 1340.

Signature

Date

Printed name of signing official

Part B - Data Collected at Observation Sites

Site ID	Site type1	Date observed	Sample weight	Number of drivers	Number of front Passengers	Number of occupants2 belted	Number of occupants unbelted	Number of occupants with unknown belt use
Total

Standard Error of Statewide Belt Use Rate^[3] ______

Nonresponse Rate, as provided in § 1340.9(f)

Nonresponse rate for the survey variable seat belt use: ________

Footnotes - Appendix A to Part 1340

^[1] Identify if the observation site is an original observation site or an alternate observation site.

^[2] Occupants refer to both drivers and passengers.

^[3] The standard error may not exceed 2.5 percent.