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Tools for Planning and Conducting the Index
Index Utilization Plan Grid
| Community: _____________________________________ Week Beginning: __________________ |
| Monday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | | | | |
| Name | | | | |
| Tuesday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | | | | |
| Name | | | | |
| Wednesday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | | | | |
| Name | | | | |
| Thursday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | | | | |
| Name | | | | |
| Friday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | | | | |
| Name | | | | |
| Saturday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | | | | |
| Name | | | | |
| Sunday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | | | | |
| Name | | | | |
Index Utilization Plan Grid SAMPLE
| Community: _____________________________________ Week Beginning: __________________ |
| Monday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | | | Hospital campus | |
| Name | | | Cathy | |
| Tuesday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | | 5th & Main St. elementary school | | fast-food place |
| Name | | Cheryl | | Maureen |
| Wednesday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | Rt. 39, Presto Quick Shop Store | | High school | |
| Name | Therese | | Mason | |
| Thursday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | | | Post office | |
| Name | | | Clay | |
| Friday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | | | | Wal-Mart |
| Name | | | | Patti |
| Saturday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | | Farm Market | | |
| Name | | Michael | | |
| Sunday |
7 - 10 a.m. |
10 a.m. - 1 p.m. |
1 - 4 p.m. |
4 - 7 p.m. |
| Location | Catholic and Episcopal churches | Re. 39 by the library | | |
| Name | Carolyn Sue | Ike | | |
Seat Belt Utilization Index
Day of week and date: _____________________ Time of day: ________________
Location: _______________________________________________________________
Name of index taker: ____________________________________________________
Indicate belted or unbelted front seat occupants by circling appropriate block (Y for yes is belted; N for no belt) that corresponds to the number of the vehicle observed. This index applies to passenger cars and pick-up trucks only. Type of Vehicle: C = Car, P = Pick-up.
| Vehicle |
Type |
Driver |
Passenger |
|
Vehicle |
Type |
Driver |
Passenger |
|
Vehicle |
Type |
Driver |
Passenger |
| 1 | ___ | Y N | Y N |
34 | ___ | Y N | Y N |
67 | ___ | Y N | Y N |
| 2 | ___ | Y N | Y N |
35 | ___ | Y N | Y N |
68 | ___ | Y N | Y N |
| 3 | ___ | Y N | Y N |
36 | ___ | Y N | Y N |
69 | ___ | Y N | Y N |
| 4 | ___ | Y N | Y N |
37 | ___ | Y N | Y N |
70 | ___ | Y N | Y N |
| 5 | ___ | Y N | Y N |
38 | ___ | Y N | Y N |
71 | ___ | Y N | Y N |
| 6 | ___ | Y N | Y N |
39 | ___ | Y N | Y N |
72 | ___ | Y N | Y N |
| 7 | ___ | Y N | Y N |
40 | ___ | Y N | Y N |
73 | ___ | Y N | Y N |
| 8 | ___ | Y N | Y N |
41 | ___ | Y N | Y N |
74 | ___ | Y N | Y N |
| 9 | ___ | Y N | Y N |
42 | ___ | Y N | Y N |
75 | ___ | Y N | Y N |
| 10 | ___ | Y N | Y N |
43 | ___ | Y N | Y N |
76 | ___ | Y N | Y N |
| 11 | ___ | Y N | Y N |
44 | ___ | Y N | Y N |
77 | ___ | Y N | Y N |
| 12 | ___ | Y N | Y N |
45 | ___ | Y N | Y N |
78 | ___ | Y N | Y N |
| 13 | ___ | Y N | Y N |
46 | ___ | Y N | Y N |
79 | ___ | Y N | Y N |
| 14 | ___ | Y N | Y N |
47 | ___ | Y N | Y N |
80 | ___ | Y N | Y N |
| 15 | ___ | Y N | Y N |
48 | ___ | Y N | Y N |
81 | ___ | Y N | Y N |
| 16 | ___ | Y N | Y N |
49 | ___ | Y N | Y N |
82 | ___ | Y N | Y N |
| 17 | ___ | Y N | Y N |
50 | ___ | Y N | Y N |
83 | ___ | Y N | Y N |
| 18 | ___ | Y N | Y N |
51 | ___ | Y N | Y N |
84 | ___ | Y N | Y N |
| 19 | ___ | Y N | Y N |
52 | ___ | Y N | Y N |
85 | ___ | Y N | Y N |
| 20 | ___ | Y N | Y N |
53 | ___ | Y N | Y N |
86 | ___ | Y N | Y N |
| 21 | ___ | Y N | Y N |
54 | ___ | Y N | Y N |
87 | ___ | Y N | Y N |
| 22 | ___ | Y N | Y N |
55 | ___ | Y N | Y N |
88 | ___ | Y N | Y N |
| 23 | ___ | Y N | Y N |
56 | ___ | Y N | Y N |
89 | ___ | Y N | Y N |
| 24 | ___ | Y N | Y N |
57 | ___ | Y N | Y N |
90 | ___ | Y N | Y N |
| 25 | ___ | Y N | Y N |
58 | ___ | Y N | Y N |
91 | ___ | Y N | Y N |
| 26 | ___ | Y N | Y N |
59 | ___ | Y N | Y N |
92 | ___ | Y N | Y N |
| 27 | ___ | Y N | Y N |
60 | ___ | Y N | Y N |
93 | ___ | Y N | Y N |
| 28 | ___ | Y N | Y N |
61 | ___ | Y N | Y N |
94 | ___ | Y N | Y N |
| 29 | ___ | Y N | Y N |
62 | ___ | Y N | Y N |
95 | ___ | Y N | Y N |
| 30 | ___ | Y N | Y N |
63 | ___ | Y N | Y N |
96 | ___ | Y N | Y N |
| 31 | ___ | Y N | Y N |
64 | ___ | Y N | Y N |
97 | ___ | Y N | Y N |
| 32 | ___ | Y N | Y N |
65 | ___ | Y N | Y N |
98 | ___ | Y N | Y N |
| 33 | ___ | Y N | Y N |
66 | ___ | Y N | Y N |
99 | ___ | Y N | Y N |
Total number of drivers observed: _______
Cars: _______ Pickups: _______
Total number of drivers with shoulder belts: _______
Cars: _______ Pickups: _______
Total number of passengers observed: _______
Cars: _______ Pickups: _______
Total number of passengers with shoulder belts: _______
Cars: _______ Pickups: _______
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