Apply for Membership

Please complete the following information to submit your Honor Roll application 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 Honor Roll is only available to Nebraska organizations.

Required fields are displayed in bold.

Organizational Information

Organization/Community: Contact Person: Email: Phone: Fax: Address: City: State: Zip: Organization Leader:

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: