1. Location:

2. School Name(s): 

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

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

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

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

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

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

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

10. Comments:

T