Come Home Safe Program

School Information

School Name: Address: City: State: - select state - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Phone: Fax: Email: Principal: Contact Name: Contact Title: Contact Email: Contact Phone: Contact Fax:

Safety Belt Usage

Enter the results of two unannounced observational surveys conducted in parking lots at least 30 days apart. Usage rates from each survey must be 90% or greater to qualify for the Honor Roll. These are due by the end of the month for presentation by the Governor in the following month:

Survey #1

Date: Total # Observed: # Wearing Safety Belts: % Wearing Safety Belts: Name(s) of Observers:

Survey #2

Date: Total # Observed: # Wearing Safety Belts: % Wearing Safety Belts: Name(s) of Observers:

Please provide a brief summary of the data collection procedures used:

Safety Belt Information