Come Home Safe Program

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Please complete the following information to submit your Come Home Safe results electronically. The Organization Leader you indicate under the Organization Information section of this form will receive a letter of congratulations if the application is accepted. Membership in the Come Home Safe program is only available to Nebraska schools.

Required fields are displayed in bold.

School Information

School Name: Address: City: State: 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 80% 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

Educational Plans for Safety Awareness

Safety Belt Check Date #1:
(One check will qualify you to be entered in the drawing for $500.)

Safety Belt Check Date #2:
(To qualify for the Honor Roll and the $1000 prize you must complete two checks 30 days apart. See attached letter for details)

School Crash History
(Has anyone in your community or school experienced a car crash that could teach to the importance of wearing safety belts?)

Total School Enrollment: