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1. Location:

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2. School Name(s): 

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3. How far do you live from your child's school?

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4. How often do your children walk or ride a bike to school?

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5. How safe do you feel it is to walk in your community?

  Extremely safe Safe Neutral Unsafe Extremely Unsafe
During the day
At night

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6. What are your top 3 concerns about walking in your neighborhood (Please select 3)?

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7. Which 3 improvements would help you feel better about walking in your neighborhood?

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8. Have you witnessed a child who was hit, or almost hit by a car?

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9. What would motivate you to walk in your neighborhood (Please select top 3)?

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10. Comments:

T