*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 with all passengers belted during final week 4 survey:

How many vehicles were surveyed during final week 4 survey?

Percent of people buckled up during final week 4 survey:

3.Adult Sponsor Verifying Results: