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2. School Name:
4. 1. What grade is your child in? (K-8)
6. 2. Is the child male or female?
8. 3. How many children do you have in Kindergarten through 8th grade?
10. 4. What is the street intersection nearest your home? (provide the names of two intersecting streets)
12. Street Name
13. and
14. Street Name
16. 5. How far does your child live from school?

    1. Less than 1/4 mile
    2. 1/4 mile up to 1/2 mile
    3. 1/2 mile up to 1 mile
    4. 1 mile up to 2 miles
    5. More than 2 miles
    6. Don't know
17. 6. On most days, how does your child arrive at school?

    1. Walk
    2. Bike
    3. School Bus
    4. Family Vehicle (only with children from your family)
    5. Carpool (riding with children from other families)
    6. Transit (city bus, subway, etc.)
    7. Other (skateboard, scooter, inline skates, etc.)
19. 7. How long does it normally take your child to get to school?

    1. Less than 5 minutes
    2. 5-10 minutes
    3. 11-20 Minutes
    4. More than 20 minutes
    5. Don't Know/Not Sure
20. 8. Has your child asked you for permission to walk or bike to/from school in the last year?

    1. Yes
    2. No
22. 9. At what grade would you allow your child to walk or bike without an adult to/from school?
24. I would not feel comfortable at any grade

    1. Yes
26. 10. Which of the following issues affected your decision to allow, or not allow, your child to walk or bike to/from school?
28. Distance

    1. Yes
    2. No
29. Child's before or after-school activities

    1. Yes
    2. No
31. Convenience of Driving

    1. Yes
    2. No
32. Speed of traffic along route

    1. Yes
    2. No
34. Time

    1. Yes
    2. No
35. Amount of traffic along route

    1. Yes
    2. No
37. Adults to walk or bike with

    1. Yes
    2. No
38. Sidewalks or pathways

    1. Yes
    2. No
40. Safety of intersections and crossings

    1. Yes
    2. No
41. Crossing Guards

    1. Yes
    2. No
43. Violence or crimes

    1. Yes
    2. No
44. Weather or climate

    1. Yes
    2. No
46. Would you probably let your child walk or bike to/from school if any of the above problems were changed or improved? If so, which issues would need to be addressed??
48. In your opinion, how much does your child's school encourage or discourage walking and biking to/from school?

    1. Strongly Encourage
    2. Encourage
    3. Neither
    4. Discourage
    5. Strongly Discourage
50. How much fun is walking or biking to/from school for your child?

    1. Very Fun
    2. Fun
    3. Neutral
    4. Boring
    5. Very Boring
52. How healthy is walking or biking to/from school for your child?

    1. Very Healthy
    2. Healthy
    3. Neutral
    4. Unhealthy
    5. Very Unhealthy
54. What is the highest grade or year of school you completed?

    1. Grades 1 through 8 (elementary)
    2. Grades 9 through 11 (some high school )
    3. Grade 12 or GED (high school graduate)
    4. College 1 to 3 years (some college or technical school)
    5. College 4 years or more (college graduate)
    6. Prefer not to answer
56. Please provide any additional comments:
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58. 1. Receive an email copy of this form.
59. Email address

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