2025 Drive for Change Pre-Seat belt Check Results

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* 1. Please Complete:

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):

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

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:

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* 3. Adult Sponsor Verifying the Results: