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Dear Parent or Caregiver,

The City of Indianapolis and Health by Design have partnered on a Safe Routes to School initiative and are interested in your thoughts about walking and biking to school. This survey should take between five and ten minutes to complete. Please take it at your earliest convenience. Your responses will be kept confidential and your name will not be associated with any results.  However, after completing the survey, as an incentive for your participation, you may opt to provide your name and e-mail address to be entered into a drawing for a gift card.Your input is important to us.

This survey covers elementary and middle school students. Please complete one survey for each school in which you have a student. For example, if you have a student in elementary school and a student in middle school, please complete one survey for each school. If you have more than one student in the same school, it is not necessary to complete the survey multiple times. Please complete the survey while thinking about your oldest student.

Your student's school should also be participating in a student tally count; on two consecutive days, the first period teacher asks each student how they arrived and intend to depart from school. Be sure to ask your student's school if they have completed the tally.

If you have any questions or would like to follow up, please contact Allan Henderson at ahenderson@hbdin.org.

Thank you for your participation!

* 1. What school does your student attend?

* 2. In which district is that school located?

* 3. What is the street intersection nearest your home? (Please provide the names of two intersecting streets. For example: Meridian & 4th)

* 4. What is the grade of the student for whom you are completing this survey? (Reminder: please answer this question and those below thinking about your oldest student in this school.)

* 5. What are the grades of any other students you have at this school?

* 6. What is your student’s gender?

* 7. How far does your student live from school?

* 8. How does your student arrive to school most days?

* 9. How does your student leave from school most days?

* 10. How long does it normally take your student to get to school?

* 11. How long does it normally take your student to get to their destination after school (such as home, child care or an activity)?

* 12. In your opinion how much does your student’s school encourage or discourage walking and biking to/from school?

* 13. Has your student asked for permission to walk or bike to/from school in the last year?

* 14. At what grade would you allow your student to walk or bike to/from school without an adult?

* 15. Which of the following issues affects your decision to allow, or not allow, your student to walk or bike to/from school? (Please select all that apply.)

* 16. Would you consider letting your student walk or bike to/from school if this issue was changed or improved? (Select all that apply.)

* 17. Does your student ever walk or bike to/from school?

* 18. Please provide additional comments or tell us about specific barriers to walking or biking to/from school for your student.

* 19. How much fun is walking or biking to/from school for your student?

* 20. How healthy do you consider walking or biking to/from school to be for your student?

* 21. Do you consider walking or biking to/from school to improve your student’s  ______________ ? (Please check all that apply.)

* 22. Which of the following do you consider yourself to be? (Please check all that apply.)

* 23. What is your gender?

* 24. What is your age?

* 25. What is the highest level of schooling you completed?

* 26. Which of the following best describes the area in which you live?

* 27. How did you hear about this survey (Facebook, Twitter, Newsletter, direct e-mail, etc. - please be as specific as possible)?

T