23 CFR Part 1340, Appendix A
PART A: To be completed by the Governor's Highway Safety Representative (GR) or if applicable, the Coordinator of the State Highway Safety Office.
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
| 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 |
|---|---|---|---|---|---|---|---|---|
| Total |
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: ________