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Pedestrian/Cycling Incident Survey
1.
Where do you live?
Cabarita
Birdwoodton
Mildura South
Merbein
Mildura
Other (please specify)
2.
Address location of incident
3.
Who was involved in the incident?
Pedestrian/Vehicle
Cyclist/Vehicle
Pedestrian/Cyclist & Vehicle
Other (please specify)
4.
Age of persons involved in the incident? Tick all that apply....
Primary School Student
Secondary School Student
Adult
Child under 5 years of age
Senior Citizen
Other (please specify)
5.
Briefly describe incident
6.
In your opinion why did this incident occur?
7.
In your opinion how could this type of incident be prevented?
8.
Did you report this incident to any local or regional authorities including the police?
Yes
No
If Yes then who did you report it to and when?
9.
If reported did you get a formal response or any action to assist with your concerns?
Yes
No
Further information
10.
Do you have any further information you think may be important?
11.
List below any accessibility issues due to safety concerns that you or your family/neighbours or friends may have. Example - access to public transport, access to school, access to leisure areas within the community
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12.
Contact Information (Optional, you won't be added to our mailing list)
Name
Company
Email Address
Phone Number
