Title 23

Appendix A to Part 1340 - State Seat Belt Use Survey Reporting Form

23:1.0.3.17.5.5.1.1.53 : Appendix A

Appendix A to Part 1340 - State Seat Belt Use Survey Reporting Form

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