23 CFR Part 1340, 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.
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.
Printed name of signing official
|Site ID||Site type 1||Dateobserved||Sample weight||Number of drivers||Number of front Passengers||Number of occupants 2 belted||Number of occupants unbelted||Number of occupants withunknownbelt use|
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: ____
Title 23 published on 2015-04-01.
No entries appear in the Federal Register after this date, for 23 CFR Part 1340.