Seat Belt Survey


You can print this sheet
and answer the questions

Name ____________________________                  Circle your answer

1.  Do you wear a safety belt when you ride in 
    the front seat of a car or truck?              yes  no  sometimes

2.  Do you wear a safety belt when you ride in 
    the back seat of a car or truck?               yes  no  sometimes

3.  Do you wear a safety belt on short trips?      yes  no  sometimes

4.  Do you wear a safety belt on long trips?       yes  no  sometimes

5.  Do you ask people riding with you to fasten
    their safety belts?                            yes  no  sometimes

6.  Does your Mother or guardian use a 
    safety belt?                                   yes  no  sometimes

7.  Does your Father or guardian use a 
    safety belt?                                   yes  no  sometimes

8.  Does your sister wear a safety belt?           yes  no  sometimes

9.  Does your brother wear a safety belt?          yes  no  sometimes

8.  Do you think it is important to use 
    a safety belt?                                 yes  no  

9.  Do you know someone that has been in 
    an auto accident?                              yes  no  

10. Did that auto accident make you think 
    about wearing your seat belt very time you 
    ride in a car or truck?                        yes  no  

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