Requested Information by Michigan State University for Safe Routes to School Evaluation

Survey Request Form (Please print or type)

Complete this form fully and return it to MSU to begin the SR2S survey process. All survey orders are shipped in 7-10 days from MSU’s receipt of this order form. Please plan accordingly to ensure surveys are received in a timely manner.

School Name

SR2S Contact Person

Email Phone

Address to mail survey materials

What grades are participating in SR2S? Check all that apply.

K / 1st / 2nd / 3rd / 4th / 5th / 6th / 7th / 8th

Each school will implement three surveys:

·  Travel Behavior Tally – completed in all classrooms with teacher assistance. Order Travel Behavior Tally below.

·  Student Survey – should be completed online only in the school’s computer lab by 3rd through 8th graders. Click here to access the Student Survey or visit

o  If your school cannot administer surveys online, see Special Notes below.

o  Make sure your school has the capacity to use the online survey. Click here to see technical requirements or visit .

·  Parent Survey (one per household) – completed online and/or by hard copy.

o  Click here to access the student Parent Survey or visit

o  Or order hard copies below.


·  If you are interested in the Spanish or Arabic versions of the surveys, they must be completed in hard copy. Order copies below.

·  If your school does not have a computer lab or meet the technical requirements, please contact Christine Vogt at or 517.432.0318 for further instructions.


Travel Behavior Tally (order 1 per classroom) enter quantity

Student Surveys Must be done online (see above.) If you need the Spanish version in hard copy, you may order it below.

Spanish enter quantity – 1 per student for 3rd through 8th graders only

Parent (1 per household) Surveys (order for households not able to complete the survey online)

Arabic enter quantity Spanish enter quantity English enter quantity