Action Plan Components
For each question below, answer “YES” or “NO.” If “YES,” list the relevant plan(s) or supporting documentation that address the condition and the specific page number(s) in each document that corroborates your response. This form provides space to reference multiple plans, but please list only the most relevant document(s).
1. Leadership Commitment and Goal Setting
Are BOTH of the following true?
• A high-ranking official and/or governing body in the jurisdiction publicly committed to an YES eventual goal of zero roadway fatalities and serious injuries; and NO• The commitment includes either setting a target date to reach zero OR setting one or more targets to achieve significant declines in roadway fatalities and serious injuries by a specific date.
Note:
This may include a resolution, policy, ordinance, executive order, or other official announcement from a high-ranking official and the official adoption of a plan that includes the commitment by a legislative body.
If “YES,” please list the relevant document(s) and page number(s) that corroborate your response.
Document Title Page Number(s)
2. Planning Structure
YESTo develop the Action Plan, was a committee, task force, implementation group, or similar body established and charged with the plan’s development, implementation, and monitoring? NO
Note: This should include a description of the membership of the group and what role they play in the development, implementation, and monitoring of the Action Plan.
If “YES,” please list the relevant document(s) and page number(s) that corroborate your response.
Document Title Page Number(s)
SS4A Self-Certification Eligibility Worksheet | Page 2 of 5