23 CFR Appendix A to Part 1340, State Seat Belt Use Survey Reporting Form

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Appendix A to Part 1340 - 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

Part B - Data Collected at Observation Sites

Site ID Site type 1 Date
observed
Sample weight Number of drivers Number of front Passengers Number of occupants 2 belted Number of occupants unbelted Number of occupants with
unknown
belt use
Total

Standard Error of Statewide Belt Use Rate 3___

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

2 Occupants refer to both drivers and passengers.

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: ____

This is a list of United States Code sections, Statutes at Large, Public Laws, and Presidential Documents, which provide rulemaking authority for this CFR Part.

This list is taken from the Parallel Table of Authorities and Rules provided by GPO [Government Printing Office].

It is not guaranteed to be accurate or up-to-date, though we do refresh the database weekly. More limitations on accuracy are described at the GPO site.


United States Code
U.S. Code: Title 23 - HIGHWAYS

Title 23 published on 2015-11-14.

No entries appear in the Federal Register after this date, for 23 CFR Part 1340.