Advocates for Highway and Auto Safety

Crash Survivor Information

Have you been affected by a crash? Since its inception in 1989, Advocates for Highway and Auto Safety (Advocates) has worked with “survivor advocates” to advance and protect highway safety laws throughout the country. Survivor advocates have suffered the personal consequences of motor vehicle crashes - either have personally survived a crash, or have had a loved one killed or injured in a crash. Bravely, they have decided to “put a face on an issue” to try to protect others from the pain and loss that they have had to endure.

Advocates is building a network of survivor advocates. If you are interested in working with us to change laws and improve highway and auto safety, please fill out the form below and hit the "submit" button. Completion of this form indicates that you wish to be added to our Survivor Advocate Network. In becoming a member of this network, you will receive information regarding pertinent legislative activity in your state and highway and auto safety issues that are relevant to circumstances you mention in your crash survivor story.

All your personal information will be kept strictly confidential.

In advance, we thank you for your interest, your time and your participation

Name (First and Last)
Address
City, State, Zip
Telephone	(Home) (Work) (Cell)
Fax
Email
Your Gender	Male Female
Crash Specifics Did your crash involve (check as many as applicable):
Speeding	A red light runner	A teenage driver
A pedestrian	A drunk or drugged driver	A motorcycle

Your Survivor Story

Date of Crash	(dd/mm/yyyy)
Vehicle You Were In (Year, Make, Model)
If other vehicles were involved, what type were they?	Car Truck	Large Truck Sport Utility
Were you wearing a seat belt?	Yes No
Were there other adults in the vehicle? Were they wearing seat belts?	Yes No Yes No

If there were children in the vehicle, were they seated in a:	Car Seat Booster Seat Seat Belt Unrestrained

If your vehicle had air bags, did they deploy?	Yes No
Were you injured?	Yes No
Was anyone else injured?	Yes No
Was anyone killed?	Yes No
Did the police respond to the crash?	Yes No
How did you hear about Advocates?	Newspaper Radio Television Web link Friend

Please use the following space to describe your survivor story.

Submission of this form indicates that you agree to be added to our Survivor Advocate Network.

Click this button when you are ready to send.
Click this button if you want to start over.

© 2007 Advocates for Highway & Auto Safety
750 First St. NE, Suite 901, Washington, DC 20002 Phone: 202 / 408-1711 Fax: 202 / 408-1699