Name of Jurisdiction:_______________________________________

Sponsoring Agency:________________________________________

Date of Scheduled Show:____________________________________

Starting Time:______________________________________________

Person Completing Questionnaire:____________________________

Title:______________________________________________________

Telephone:________________________Fax:_____________________

E-Mail:____________________________________________________

Population:___________________ Community Type: Urban____Rural____Suburban____

Population Trends: ____________________________________________________________________ ____________________________________________________________________

Brief Description of the Community: (types of industry, density, media outlets, magnitude of traffic problems, etc.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Reason for Sponsoring Road Show: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Number of Pedestrian Crashes/YR:___________ Pedestrian Fatalities/Yr.________

Distribution of Crashes by Pedestrian Age: 0-4______ 5-9______ 10-15______ 15-19__ ____  20-64______ 65+______

Distribution of Crashes by Location: Commercial/Business:__________Residential:_________Intersection:_ ___ _____ Non-Intersection:_________

Major Pedestrian Error Leading to Crashes: ______________________________________________________________________________ ______________________________________________________________________________

Major Motorist Error Leading to Crashes: ______________________________________________________________________________ ______________________________________________________________________________

Pedestrian Crash Trends: Are crashes increasing, decreasing, changing demographics? ______________________________________________________________________________ ______________________________________________________________________________

Sidewalk Policy: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Recent Pedestrian Improvements: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Pedestrian Projects in Transportation Improvement Program: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Use of Traffic Calming Devices: (e.g. speed humps, roundabouts, etc.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Greatest Facility Concerns: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Recent Pedestrian Safety Initiatives: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Pedestrian Safety Education in Schools: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Pedestrian Safety Enforcement Activity: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Pedestrian Public Information Efforts: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Level of Citizen Interest in Pedestrian Safety: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Level of Official Support for Pedestrian Safety Programs: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________