Large random Sampling of  citizen seatblelt use


This information is collected anonymously. Thank you for participating!

Please select you age group  

Your Gender:   Male Female 

Do you own or operate a motor vehicle on a regular basis?  Yes    No

Was you vehicle equipped with a seatbelt? Yes   No
Was you vehicle equipped with airbag?   Yes   No
Honestly counts here... Were you wearing your seatbelt ? Yes   No






Please list your state 


Have you been in a vehicle accident? YES   or   NO

Did you get inuries during this accident   YES  or  NO


Briefly describe your car accident,number of vehicles involved, T-bone, Hit a tree etc.


Please rate the severities of injuries from that crash (if any)

Passenger 1                                              Passenger 2                                                Passneger 3