23 C.F.R. § 1340 app A to Part 1340
Current through September 30, 2024
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 | Date observed | Sample weight | Number of drivers | Number of front Passengers | Number of occupants belted | Number of occupants unbelted | Number of occupants with unknown belt use |
| Total |
Identify if the observation site is an original observation site or an alternate observation site.
Occupants refer to both drivers and passengers.
Standard Error of Statewide Belt Use Rate ______
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: ________
23 C.F.R. § 1340 app A to Part 1340