Seatbelt Survey Analysis Form Information About Your School Name Of School: County Name: Sponsor Name: Your Email Address: Send A Copy Of This Completed Form To Email Address: Survey Type: [ Select ] Baseline Survey Mid Survey Final Survey Day 1 Data Collection Day 1 - Date Of Collection: Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Totals Total Number Of Drivers Belted (Y) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Drivers Not Belted (N) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Drivers On A Phone (P) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Drivers Texting (T) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Drivers Otherwise Distracted (O) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Drivers With No Distractions (N) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Passengers Belted (Y) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Passengers Not Belted (N) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Day 2 Data Collection Day 2 - Date Of Collection: Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Totals Total Number Of Drivers Belted (Y) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Drivers Not Belted (N) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Drivers On A Phone (P) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Drivers Texting (T) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Drivers Otherwise Distracted (O) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Drivers With No Distractions (N) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Passengers Belted (Y) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Total Number Of Passengers Not Belted (N) Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Total Summary Percent Of Drivers & Passengers Belted: % Percent Of Drivers Distracted: % Comments: