Shipley Reimagined - CityConnect Baseline Monitoring

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Email *

Name *

Event Attended (if applicable)

Date Attended

YYYY

Home Postcode *

Date of Birth *

YYYY

Q1. Employment Status

If "Other" please specify

Full time

Part time

Job seeker

Apprentice

Not currently working

Full time education/training

Part time education/training

Other:

Clear selection

Q2. Place of employment/education/training?

Q3. Do you have access to a working bike?

I have my own bike

I share with my family or friend

I sometimes hire a bike

Clear selection

Q4. Why do you ride? (check all that apply)

To get from A to B

Leisure

Fitness

Social

Q5. How often do you ride?

Daily

Weekly

Monthly

Less Often

Never

Clear selection

What would encourage you to ride more? (check all that apply)

Better bike

Better equipment

Having more time

Confidence

Safer cycling routes

Better facilities at work

Better awareness from drivers

CONSENT

The information which you provide will only be used in the manner described in the attached privacy notice (https://goo.gl/C3mZMw). If you agree to allow the West Yorkshire Combined Authority (WYCA) to use your information as specified, please provide your consent by ticking the appropriate boxes below.

I consent to WYCA using my personal data above, for the purpose of monitoring and evaluating the impact of the Confident Commuter Package project managed by Bradford Capital of Cycling I understand that this may involve WYCA or someone nominated by it contacting me [by email] at a further date with a follow-up survey to assess the impact of the programme.

Please tick here if you consent to us using your data for the monitoring and evaluation purposes specified

Please tick here if you consent to other follow-up contact

Required

* You can withdraw your participation at any time by contacting us at the following address: CityConnect Team, Wellington House, 40-50 Wellington Street, Leeds, LS1 2DE E-Mail: cityconnect@westyorks-ca.gov.uk Tel: 0113 2517366.

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