Code of Federal Regulations Title 23. Highways 23 CFR Pt. 1340, App. A—STATE SEAT BELT USE SURVEY REPORTING FORM

PART A:  To be completed by the Governor's Highway Safety Representative (GR) or if applicable, the Coordinator of the State Highway Safety Office.

State:  __________________

Calendar Year of Survey:  _________

Statewide Seat Belt Use Rate:  _______

I hereby certify that:

• ________has been designated by the Governor as the State's Highway Safety Representative (GR), and if applicable, the GR has delegated the authority to sign the certification in writing to _________, the Coordinator of the State Highway Safety Office.

• The reported Statewide seat belt use rate is based on a survey design that was approved by NHTSA, in writing, as conforming to the Uniform Criteria for State Observational Surveys of Seat Belt Use, 23 CFR Part 1340.

• The survey design has remained unchanged since the survey was approved by NHTSA.

• ________, a qualified survey statistician, has reviewed the seat belt use rate reported above and information reported in Part B and has determined that they meet the Uniform Criteria for State Observational Surveys of Seat Belt Use, 23 CFR Part 1340.

Signature

Date

Printed name of signing official

¹ Identify if the observation site is an original observation site or an alternate observation site.

² Occupants refer to both drivers and passengers.

Standard Error of Statewide Belt Use Rate  3___

 The standard error may not exceed 2.5 percent.

Nonresponse Rate, as provided in § 1340.9(f)

Nonresponse rate for the survey variable seat belt use:  ____