Safe Routes Philly Teacher Completion Form
BASIC INFORMATION
Name (First, Last)
Your answer
Email
Your answer
Phone
Your answer
School
Your answer
What subjects do you teach?
Have you attended a Safe Routes Philly Professional Development training in the past?
Did a Safe Routes Philly representative come to your school to train you on the curriculum?
CURRICULUM: Pedestrian Safety Lessons
In the fields below, please enter the total number of students in each grade who received a Pedestrian Safe Routes Philly lesson.
K
Your answer
1
Your answer
2
Your answer
3
Your answer
4
Your answer
5
Your answer
6
Your answer
7
Your answer
8
Your answer
What month did you teach Pedestrian Safety?
*if you taught different grades in different months, choose the month you started teaching.
CURRICULUM: Bicycle Safety Lessons
In the fields below, please enter the total number of students in each grade who received a Bicycle Safe Routes Philly lesson.
K
Your answer
1
Your answer
2
Your answer
3
Your answer
4
Your answer
5
Your answer
6
Your answer
7
Your answer
8
Your answer
What month did you teach Bicycle Safety?
*if you taught different grades in different months, choose the month you started teaching.
CURRICULUM: Evaluation and Support
Did you partner with classroom teachers to deliver the safety lessons?
Check the resources that you used to teach the safety lessons:
What videos did you use to compliment the lessons?
Mark how you accessed the activity book pages?
Additional Pedestrian Lessons Taught
Additional Bicycle Lessons Taught
I felt prepared to teach Safe Routes Philly lessons
1 is strongly disagree. 2 is disagree. 3 is neutral. 4 is agree. 5 is strongly agree
Strongly Disagree
Strongly Agree
The Safe Routes Philly materials were relevant to the age group(s) taught.
1 is strongly disagree. 2 is disagree. 3 is neutral. 4 is agree. 5 is strongly agree
Strongly Disagree
Strongly Agree
Students were involved and engaged in the lessons.
1 is strongly disagree. 2 is disagree. 3 is neutral. 4 is agree. 5 is strongly agree
Strongly Disagree
Strongly Agree
Additional Comment Welcome!
Your answer
THANK YOU!
We appreciate the time you took to fill out this form. The data collected here allows us to better understand our impact and helps us continue to secure funding* for our programs.
*Safe Routes Philly is funded by the Philadelphia Department of Health

Contact me if you have any questions or suggestions:
Waffiyyah Murray
waffiyyah@bicyclecoalition.org
215-242-9253 EXT: 312

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