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Parent Survey About Walking and Biking to School <br />Dear Parent or Caregiver, <br />Your child's school wants to learn your thoughts about children walking and biking to school. This survey will take about 5 - 10 minutes to <br />complete. We ask that each family complete only one survey per school your children attend. If more than one child from a school brings a <br />survey home, please fill out the survey for the child with the next birthday from today's date. <br />After you have completed this survey, send it back to the school with your child or give it to the teacher. Your responses will be kept <br />confidential and neither your name nor your child's name will be associated with any results. <br />Thank you for participating in this survey! <br />+ <br />CAPITAL LETTERS ONLY — BLUE OR BLACK INK ONLY + <br />School Name: <br />1. What is the grade of the child who brought home this survey? m Grade (PK,K,1,2,3 .) <br />2. Is the child who brought home this survey male or female? 11 Male Female <br />3. How many children do you have in Kindergarten through 8a' grade? m <br />4. What is the street intersection nearest your home? (Provide the names of two intersecting streets) <br />and <br />Place a clear `X' Inside box. If you make a mistake, fill the entire box, and then mark the correct box. <br />5. How far does your child live from school? <br />❑ Less than "/4 mile 'k mile up to 1 mile ❑ More than 2 miles <br />"/4 mile up to 1/2 mile 1 mile up to 2 miles 1-3 Don't know <br />Place a clear `X' inside box. If you make a mistake, fill the entire box, and then mark the correct box. + <br />6. On most days, how does your child arrive and leave for school? (Select one choice per column, mark box with X) <br />Arrive at school heave from school <br />Walk Walk <br />E] Bike Bike <br />❑ School Bus School Bus <br />Family vehicle (only children in your family) Family vehicle (only children in your family) <br />Carpool (Children from other families) Carpool (Children from other families) <br />Transit (city bus, subway, etc.) Transit (city bus, subway, etc.) <br />rlOther (skateboard, scooter, inline skates, etc.) Other (skateboard, scooter, inline skates, etc.) <br />+ <br />I Place a clear `X' inside box. If you make a mistake, fill the entire box, and then mark the correct box <br />+ <br />7. How long does it normally take your child to get to /from school? (Select one choice per column, mark box with X) <br />Travel time to school Travel time from school <br />Less than 5 minutes Less than 5 minutes <br />5 — 10 minutes 5 — 10 minutes <br />11 -20 minutes 11 —20 minutes <br />More than 20 minutes More than 20 minutes <br />E] Don't know / Not sure Don't know / Not sure <br />+ I { <br />