*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.)

Total number of vehicles checked during Pre Seat Belt Check:

Total number of vehicles checked with all occupants belted:

Final percentage of seat belt usage:

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