*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 pre- campaign survey?

Total number of vehicles with ALL passengers belted during the pre- campaign survey:

Percent of people buckled up during the pre- campaign survey:

*3.Adult Sponsor Verifying the Results:(Required.)