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* 1. How old are you?

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* 2. Please tell us the town and area of the town you live in.

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* 3. What is the speed limit on your street?

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* 4. Rate your agreement with the following statements about road safety on your street:

  Strongly agree Agree Neither agree nor disagree Disagree Strongly agree
Vehicles travel at a safe speed on my street
There are enough safe places to cross my street
I feel safe from road danger on my street
There are safe footpaths/pavements to walk on my street
I would feel safe cycling on my street

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* 5. Do any of the following factors negatively affect your wellbeing?

  Yes  No I don't know
The volume of traffic on my street
The speed of traffic on my street

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* 6. Which of the following do you consider to be the BIGGEST threat to your health and safety on your street? (Tick one)

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* 7. Which of the following do you feel would make your street safer?

  Yes No I don't know
More footpaths/pavements for walking
More segregated cycle paths or cycling
A reduction in the speed limit
More traffic calming measures, such as speed humps
More safe places to cross

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* 8. Are you able to get to a transport hub (tram, train or bus stop/station) safely by ...?

  Yes No I don't know
Walking
Cycling

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* 9. Is there a specific issue of road safety that you would like to highlight? Please be as specific as possible with the areas/road mentioned.

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* 10. If you would like to be contacted please provide your name, email address and telephone number.

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