KENTUCKY DEPARTMENT OF TRANSPORTATION SAFETY - MAKE A SAVED BY THE BELT NOMINATION


PURPOSE To identify individuals in Kentucky whose lives are saved or injuries significantly reduced because they were wearing a safety belt or protected by an air bag and a safety belt at the time of a crash. To identify individuals whose lives are saved or injuries significantly reduced because they were properly wearing a safety belt or were in a safety seat or protected by an air bag and a safety belt at the time of the crash To provide documented evidence of cases where safety belts and other occupant protection devices “made the difference” To reinforce the life-saving importance of occupant protection for individuals involved in motor vehicle crashes and encourage others to use them To increase public awareness on the benefits of use of safety belts, air bags and child safety seats WHO QUALIFIES Persons who are eligible for receiving the award must meet all of the following criteria: Nominee must be a Kentucky resident Any person and/or their spouse and children involved in a motor vehicle crash whose lives were saved or injuries reduced because of the use of a safety restraint or air bag and safety belt The crash occurred after December 31, 1999 Nominees must be using the proper combination of safety restraints. For example, safety belts were properly used in vehicles equipped with an airbag; use of the manual lap belt is required with some automatic belt systems; child nominees who are required to be restrained by a child safety seat must be properly secured in the child restraint and the restraint must be properly secured in the vehicle by a safety belt Nominees may not be the driver of the “at-fault” vehicle; i.e., if the crash review finds the crash could have been prevented the nominee will NOT qualify REVIEW PROCEDURES Each entry will be reviewed using the following criteria: Severity of crash Severity of injuries/condition Circumstances surrounding the crash After full review, The “Saved By The Belt” Committee reserves the right not to grant the presentation of the award DISCLAIMER Nominees agree to allow the use of their name and crash information in promotional activities for the “Saved By The Belt” program, and releases the Kentucky Transportation Cabinet and its representatives from any obligation or liability associated with the awards and subsequent promotions of this program.

Nominee Information
Nominee First Name:
Nominee Middle Initial:
Nominee Last Name:
Nominee Street Number:
Nominee Street Name:
Nominee Street Address Line 2 (if needed):
Nominee City:
Nominee State:
Nominee Zip Code:
Nominee Home Phone:
Nominee Work Phone:
Nominee Email Address (if available):

Crash Information
Crash Master File Number (if available):
Crash Date (MM/DD/YYYY):
Crash County:
Crash Highway:
Brief Crash Narrative:

Submitted by Information
Submitted by First Name:
Submitted by Last Name:
Submitted by Street Number:
Submitted by Street Name:
Submitted by Street Address Line 2 (if needed):
Submitted by City:
Submitted by State:
Submitted by Zip Code:
Submitted by Home Phone:
Submitted by Work Phone:
Submitted by Date MM/DD/YYYY:
Submitted by Email Address (if available):

PURPOSE

WHO QUALIFIES

REVIEW PROCEDURES

DISCLAIMER

Nominee Information

Crash Information

Submitted by Information

Commonly Requested Numbers:

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