*1.Please Complete:(Required.)

Name of School or Youth Group:

Date Seat Belt Check was Conducted:

Survey Time (must be approximately the same time for pre and post check):

Survey Location (must be the same location for pre and post check):

*2.Seat Belt Check Results:
*Please ONLY give numerical data, no words or explanation.(Required.)

How many vehicles were checked during the post/final survey?

Total number of vehicles with ALL passengers belted during the post/final survey:

Percent of people were buckled up during the post/final survey:

3.Adult Sponsor Verifying the Results: