Title DR MISS MR MRS MS First Name * Last Name * Email Address * Position Title * -- Please select -- Principal Assistant Principal PE Teacher Art Teacher Lead Teacher Classroom Teacher School Counselor Other State * -- Please select -- AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Name of School * County * -- Please select -- Brevard Broward Collier Duval Lee Miami-Dade Monroe Orange Palm Beach Polk Santa Rosa Seminole Volusia Other If other, please specify the county below. Did your school participate in the Walk to School Day event on October 5, 2011? * Did your school implement day 1 of the curriculum (classroom discussion and videos)? * If so, was it completed on October 3, 2011? * If not, on which date(s) was day 1 completed at your school? Which grade(s) participated in day 1 of the curriculum at your school? (Please check all that apply.)
Did your school implement day 2 of the curriculum (street crossing simulation)? * If so, was it completed on October 4, 2011? * If not, on which date(s) was day 2 completed at your school? Which grade(s) participated in day 2 of the curriculum at your school? (Please check all that apply.)
Did your school implement day 3 of the curriculum (poster contest or creative activity)? * If so, was it completed on October 5, 2011? * If not, on which date(s) was day 3 completed at your school? Which grade(s) participated in day 3 of the curriculum at your school? (Please check all that apply.)
How many teachers at your school participated in teaching the WalkSafe curriculum? * How many students in GRADE K participated in the WalkSafe educational component at your school this year? * How many students in GRADE 1 participated in the WalkSafe educational component at your school this year? * How many students in GRADE 2 participated in the WalkSafe educational component at your school this year? * How many students in GRADE 3 participated in the WalkSafe educational component at your school this year? * How many students in GRADE 4 participated in the WalkSafe educational component at your school this year? * How many students in GRADE 5 participated in the WalkSafe educational component at your school this year? * How many students in OTHER GRADES (i.e. PK, 6, 7, 8) participated in the WalkSafe educational component at your school this year? * Are there any self-contained SPECIAL EDUCATION classrooms at your school? * If yes, how many students in total are there in these self-contained SPECIAL EDUCATION classrooms? Which exceptionalities are represented in these classrooms? Was the WalkSafe SPECIAL EDUCATION curriculum taught to these students? Does your school have an AAA School Safety Patrol program? * If not, what is the biggest obstacle to establishing an AAA Safety Patrol program at your school?
