Self Reporting Survey - Schlagle Final

Question Title

* 1. The last time you were in a motor vehicle, did you wear a seatbelt?

Yes

No

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* 2. 2. The last time you drove, did you text, talk on a phone, or were you otherwise distracted at any time?

Yes

No

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* 3. 3. Please list the ways you were distracted the last time you drove. (Select all that apply).

Phone

Texting

Other (Eating, radio, GPS, etc.)

I was not distracted at any time.

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* 4. Please add your name and grade.