Information about http://www.dps.state.ia.us/commis/gtsb/forms/HonorRollBooklet.pdf
Iowa Safety Belt Honor Roll Entry Form …
Tags: advocates, auto crashes, award ceremony, award recognition, belts, citizens, co workers, entities, fellow, group facility, highway traffic safety, honor roll, increased safety, jurisdiction, national highway traffic, national highway traffic safety, productive members, program quality, quality of life, safety belt,Pages: 7
Language: english
Created: Thu Nov 10 09:55:51 2005
Display cached document
Page 1
Page 2
Page 3
Page 4
Page 5
Page 6
Page 7
Iowa
Safety Belt Honor Roll
Entry Form
The Iowa Safety Belt Honor Roll
Make the Honor Roll and Help arrange a local award ceremony when they
receive their award.
Save Lives!
Hundreds of Iowa's entities were recognized
As a leader in your community, you serve an under the National Highway Traffic Safety
important function -- helping to improve the Administration 70%+ Honor Roll program.
quality of life. Highway Traffic Safety Now, with new higher award recognition
advocates at the local, state and national levels, the program offers a continued
levels are depending on you to ensure the incentive to strive for increased safety belt
safety of your most valuable asset -- people. use rates.
Every year, thousands of loved ones, valued
co-workers and fellow citizens are needlessly
hurt or killed in auto crashes. Many of these
How Do You Qualify?
injuries and fatalities could have been
prevented by safety belt use. In fact, To qualify for an award, you must conduct
numerous national studies prove that safety two unannounced safety belt observational
belts reduce the risk of serious injury or death surveys at least 30 days apart. Although it
by nearly 50 percent. isn't necessary that the entire targeted
population be surveyed, it is important that
Not only are productive members of our you observe a large enough sample to
community hurt or lost forever in these tragic substantiate a valid safety belt use rate for
crashes, but there is also a staggering the group, facility or jurisdiction. A self-
economic cost nationally estimated at $150 reporting survey that asks people about their
billion annually. Clearly, we all pay dearly safety belt use is not acceptable.
when safety belts are not used.
The idea is to get as many people within your
reach to buckle up.
Encourage Safety Belt Use
We invite you to participate in the Iowa Safety
Guidelines
Belt Honor Roll. This prestigious program,
conducted by the Iowa Governor's Traffic The same method for collecting the data
Safety Bureau (GTSB), is designed to should be used for each survey and at each
encourage safety belt use and to reward observational site. Planning should include:
those achieving 80% 85%, 90%, 95% and determining the time and location for each
100% use rates among their members or survey and selecting and training two-person
targeted population. Your target group may survey teams to collect the data -- one to
be your county, city, company, school, observe the actual belt use and the other to
military base, police department or other record this information on the data collection
organization. form. (Although it is not preferable to do so,
one surveyor working alone may conduct the
observational surveys.)
Rewards of the Honor Roll
Survey teams should be posted where they
The benefits of participation are numerous. can clearly and safely observe the driver of
You'll help save lives, act as a role model for the vehicle. Observation sites should be
others and be recognized for your efforts with selected where there is a traffic light, stop
an award for your accomplishment. sign, or entrance/exit gate where traffic slows
and belt use can be more easily determined.
Award recognition is distinguished in five Observers should not stop vehicles entering
levels: 80%, 85%, 90%, 95% and 100%. or leaving the observation point to check for
These honors can be a source of pride and belt use.
self-accomplishment for you and your
community. Many honorees choose to
A sample Driver Safety Belt Survey Form is attached. You may use the one provided or develop
your own. You are not required to submit the individual data collection forms used, but
describe how the survey was conducted in Item #2 on the Survey Results page of the
application form.
When Can You Enter?
The Iowa Safety Belt Honor Roll is an ongoing program. Applications may be submitted to the
Governor's Traffic Safety Bureau anytime throughout the year. Only one award, per achievement
level, will be awarded to a group or organization within a given year. However, organizations may
reapply as higher achievement levels are attained (e.g., you may qualify for an 80% award in
March and an 85% award in September of the same year). The GTSB can help an honor roll
awardee plan an appropriate award presentation.
The Iowa Safety Belt
Honor Roll Application Form
1. Level of safety belt use achievement: (Circle one)
80% 85% 90% 95% 100%
2. Size of targeted population (e.g., military base, employees, town residents, company plant,
combined businesses, etc.):
3. Name and location of organization/jurisdiction nominated (City/County, etc) NOT who
conducted the survey, but rather who was surveyed. Indicate exactly how name should
appear on award.
Name __________________________________________________________________
City ___________________________________________________________________
4. Official who will receive award on behalf of applicant:
Name
Title
Organization
Address
City/State/Zip
Telephone
5. Contact for follow-up questions or additional information, if needed:
Name
Title
Organization
Telephone
Complete Both Sides of This Form
The Iowa Safety Belt Honor Roll
Survey Results
1. Enter the results of two unannounced observational surveys that were conducted at least
30 days apart. The usage rates from each of the two surveys must be 80% or greater to
qualify for an award.
Survey #1 Survey #2
a. Dates of surveys ______________ ______________
month/day/year month/day/year
b. Number of drivers observed wearing ______________ ______________
safety belts.
c. Divided by the total number of drivers ______________ ______________
observed in the survey.
d. Equals: the percent of belted drivers ______________ ______________
observed in the survey (b/c x 100).
2. Summarize the procedures used in collecting the data. Include the number and
descriptions of the locations (e.g., residential, major intersections, shopping district, parking
lot, etc.) time of day observed and number of observers and their procedures.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. Name of Certifying Official (Printed or Typed): __________________________
Signature of Certifying Official: ___________________________________
Title: Date:
Mail Completed Entry Form to:
Iowa Governor's Traffic Safety Bureau
Wallace Building, 4th Floor
Des Moines, Iowa 50319-0248
Phone: 515/281-3907
Fax: 515/281-6190
Safety Belt Observation Surveys
WHY CONDUCT A SURVEY?
Results will show progress of enforcement and education in changing behaviors.
HOW TO CONDUCT THE SURVEY
There is no single way to conduct a survey. At a minimum, observations should be conducted at several
different locations and during different time periods. Survey sites should reflect different types of motor
vehicle travel such as residential, major intersections, mall entrances, or highways and freeways in the
community. Conduct subsequent surveys in the same manner. Try to use the same locations, directions of
travel, day of week and times of day.
1) Choose "key" sites in the community. Smaller populated areas should choose at least two sites and
metropolitan areas should choose at least five sites.
2) Conduct observations until one hundred vehicles are observed at each site or for one hour at each
site.
3) Observe drivers.
4) Choose a location where you can see inside the cars such as at a stop sign or at a traffic light.
5) Do Not count the cars when you cannot confirm if belts are used.
6) Use the video "How to Conduct Informal Safety Belt Surveys" to educate observers, available
through the Governor's Traffic Safety Bureau (GTSB).
7) Use the attached form for counting vehicles. Copy as needed.
8) Child restraint surveys need special instructions. Contact the GTSB.
Changes in the results of the surveys should be incorporated into local public information and press
conference materials.
Remember, the objective is to show that progress is being made toward increasing safety belt usage.
The Iowa Safety Belt Honor Roll
Sample Driver Safety Belt Survey Form
(copy as needed)
Survey Date: Time: A.M. P.M.
Survey Location
Group Conducting Survey
Indicate a belted or unbelted driver by checking the appropriate block (Yes/No) that corresponds to the vehicle surveyed.
Yes No Yes No Yes No Yes No
1. 26. 51. 76.
2. 27. 52. 77.
3. 28. 53. 78.
4. 29. 54. 79.
5. 30. 55. 80.
6. 31. 56. 81.
7. 32. 57. 82.
8. 33. 58. 83.
9. 34. 59. 84.
10. 35. 60. 85.
11. 36. 61. 86.
12. 37. 62. 87.
13. 38. 63. 88.
14. 39. 64. 89.
15. 40. 65. 90.
16. 41. 66. 91.
17. 42. 67. 92.
18. 43. 68. 93
19. 44. 69. 94.
20. 45. 70. 95.
21. 46. 71. 96.
22. 47. 72. 97.
23. 48. 73. 98.
24. 49. 74. 99.
25. 50. 75. 100.