Exit Pedestrian/Cycling Incident Survey Question Title * 1. Where do you live? Cabarita Birdwoodton Mildura South Merbein Mildura Other (please specify) Question Title * 2. Address location of incident Question Title * 3. Who was involved in the incident? Pedestrian/Vehicle Cyclist/Vehicle Pedestrian/Cyclist & Vehicle Other (please specify) Question Title * 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) Question Title * 5. Briefly describe incident Question Title * 6. In your opinion why did this incident occur? Question Title * 7. In your opinion how could this type of incident be prevented? Question Title * 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? Question Title * 9. If reported did you get a formal response or any action to assist with your concerns? Yes No Further information Question Title * 10. Do you have any further information you think may be important? Question Title * 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 1 2 3 4 5 6 7 8 9 10 Question Title * 12. Contact Information (Optional, you won't be added to our mailing list) Name Company Email Address Phone Number Done
