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2. Name (First & Last)
4. Email Address
6. Do you live on or near Pacific Avenue?*
   -- Select One --My home or business is located on Pacific AvenueMy home or business is near the project, but not on Pacific AvenueMy home or business is located in a different part of townI prefer not to say
8. Does anyone in your household participate in a free/reduced price lunch program at a local school?*
   -- Select One --YesNoPrefer not to say
10. Do you use Pacific Avenue to access any of the schools impacted by the project (Rubidoux High School, Pacific Avenue Academy of Music, Rustic Lane Elementary, or Mission Middle School)*
    -- Select One --YesNo
12. Does anyone in your household attend one of the schools listed above?*
    -- Select One --YesNo
14. If you answered yes to the above question, how many people in your household attend one of the impacted school?
    -- Select One --12345More than 5
16. Does anyone in your household walk to one of the impact schools?*
    -- Select One --YesNo
18. Does anyone in your household bike to one of the impacted schools*
    -- Select One --YesNo
20. What issues have prevented you or anyone else in your household from walking/biking to school (select one or more)
    -- Select One --Destination is not closeRoute is unsafe due to lack of sidewalks and/or bike lanesIt takes too longOther (provide details below)
22. What other issues have prevented you or anyone else in your household from walking/biking to school?
24. For what purposes would you or anyone in your household use the improvements for?

    1. Travel to school
    2. Travel to work
    3. Exercise
    4. Travel to grocery store
    5. Leisure
26. Do you support the installation of bike lanes and a crosswalk along Pacific Avenue*
    -- Select One --YesNo
28. If bike lanes and/or a crosswalk were to be constructed on Pacific Avenue, would you or anyone in your household walk or bike more?*
    -- Select One --YesNo
30. To save lives, would you be willing to add more time to your vehicular trips on Pacific Avenue? How much time?*
    -- Select One --Yes, I would be willing to add as much time as it takes to save livesYes, I would be willing to add 5 minutes to my travel to save livesYes, I would be willing to add 20 minutes to my trip to save livesNo, I would rather not add time to my tripI do not drive
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32. 1. Receive an email copy of this form.
33. Email address

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