Before Filling in the Questionnaire, Please Read the Questions Carefully

Instructions

We invite you to follow these short instructions. Be aware that some questions may require an elaborated answer which needs more time.

Before filling in the questionnaire, please read the questions carefully.
Locate all relevant documents and material on your active mobility measure which may be available in your national language.
Translate into English the text you wish to submit.
Address each question paying attention to answer all parts of it, as this will be the basis for evaluation.
Save a draft version of your questionnaire and complete it later when you have all relevant information.

Deadline for submission: 30/09/2015

After submission and a first screening, you may be contacted in case some information is incomplete. Make sure you have indicated a contact person (e-mail address and telephone number including country prefix) who is in charge of implementing the measure and can answer to additional questions.

For more information or help filling out the form, please contact:

Dr. Florinda Boschetti, Polis,, +32 2 500 56 74

1. Details of applicant
Local authority / Association
Country
Address
Street / Post box
Postal code
City
Country
Contact person
Name and Surname
Position / profile
Office, Department
Telephone
E-mail address
About your city
What is your city/town size? / Please tick one box:
Up to 100.000 inhabitants
100.000-500.000
More than 500.000
2. Background & Policy Objectives
Q2.1
Describe the main challenges your city/town is facing in relation to urban transport.
Explain why you are implementing measures to increase active mobility (walking and cycling). / Free text (max 500 words)
3. Active mobility measure: Background
Q3.1
What is the domain of your active mobility measure? / Please tick one box only:
Strategic policy
Social environment
(Measures intended to change social norms and attitudes through information and supportive structures)
Physical environment/infrastructure
(These are measures to change the physical environment such as infrastructure for walking and cycling, green area development, localisation, etc.)
Regulation and legislation
(Top-down measures which can range over different geographical levels. E.g., piece of legislation, laws)
Q3.2
What mode(s) of transport is you measure focused on? / Please tick on or more boxes (Multiple choice):
Walking
Cycling(including bikesharing)
Public transport use
Other (e.g. bike ride, car-sharing, skateboarding, etc.)
All non-motorised modes
Q3.3
What is your target population and the level of action (i.e. neighbourhood, city, regional, national)? / Free text (max 250 words)
Q3.4
Which other partners are involved?
Please list the:

Sectors (transport, environment, social welfare, health, land use planning ...),
Levels of governance (e.g. other local authorities, regional authorities, national government)
Local partners (e.g. transport operators, private companies, user groups, associations)

you cooperate with for the implementation of your active mobility measure.
Please describe the means of engagement and how you involved them, as well as the focus/purpose of their involvement. / Free text (max 500 words)
4. Active mobility measure: Description
Q4.1
Please tell us your active mobility measure’s name/title. / Title
Q4.2
Describe your measure, including implementation timeframe, financing method and costs. / Free text (max 500 words)
Q4.3
Please describe what the expected results are after implementing your active mobility measure.
Please try to identify the value added for your targets in the Economic, Social, Ecological and Institutional dimensions. / Free text with examples (max 500 words)
Q4.4
What specific social, physical and environmental circumstances have contributed to success?
Or what circumstances have hampered your active mobility measure implementation? / Free text with examples (max 500 words)
Q4.5
Please describe if and by what means you have evaluated your active mobility measure.
Can you report on what results were achieved (e.g. Increased level of active mobility, health-enhancing physical activity outcomes)? / Free text with examples (max 500 words)
5. Documentation of project outcomes or progress (desired)
Q5.1
Attach any useful material about your active mobility measure (project documentation, monitoring or evaluation reports, scientific papers or leaflets, images). / Please send as an attachment when submitting this document.
6. Health Economic Assessment Tool (HEAT)
Q6.1
Do you know the Health Economic Assessment Tool (HEAT) developed by the World Health Organisation? / Yes
No
Q6.2
Have your city used HEAT to assess your active mobility measure? / Free text with examples (max 250 words)

Many thanks!!

To return the form with any supporting documentation, please send to Dr. Florinda Boschetti, Polis,