Please provide the following information about yourself and your organisation. This information is optional but completing may help us to help you and others. Your data will be stored securely and treated as confidential.

1.	Title (Dr, Mr, Mrs, Ms)

2.	First name

3.	Surname

4.	Job Title

5.	Job Function

6.	Email address (this will only be used by us to contact you about your evaluation and use of the toolkit)

7.	Phone Number

8.	Organisation

The following questions will inform the evaluation recommendations for your project.

9.	What road safety issue are you trying to address?

10.	What evidence do you have to support this issue? (i.e. How can you demonstrate the need for your intended project?)

11.	What do you expect the total financial cost of the project to be? (Enter in numbers, do not use pound signs, spaces, or commas)

12.	Who is going to lead your evaluation? (Name and role if known)

13.	Is your ETP intervention linked to: (please select one)
	Engineering
	Enforcement
	Neither Engineering nor Enforcement
	Both

14.	What do you hope to change by your programme of work? These are your aims and should relate to a measurable outcome, e.g. your aim could be to increase the safety of children's road crossing behaviour. You might have more than one aim.

15.	By when do you hope to achieve these outcomes? e.g. A measured improvement in the safety of road crossing behaviour in all Year 4 children by July 2010

16.	Have you identified objectives for your programme of work?
	Yes
	No

17.	Please state your objectives (Your objectives are how you intend to achieve your aims, e.g. Year 4 children will receive skill training in recognising safe versus dangerous crossing places)

If you have not yet identified specific objectives for how you intend to achieve your aim, it is best to do so before completing the rest of the questions.

18.	Please provide a summary of your campaign:

There are three ways to measure progress towards your outcome. Please read through the following options and decide which you intend to use to answer Q.19

Option 1: Monitoring (Remote indicator) For example: The number of Year 4 children who receive Safe places training

Option 2: Indirect measure (Impact indicator) For example: Do trained Year 4 children show greater awareness of the dangers of crossing the road?

Option 3: Direct measure (Outcome indicator) For example: Comparison of the construction of safe routes to cross a road amongst trained and control groups of Year 4 children

19.	How do you intend to measure progress towards your outcome? (you can select more than one)
	Option 1: Remote indicator
	Option 2: Impact indicator
	Option 3: Outcome indicator

20.	Please identify the source of your evaluation data. For example: Register of pupils attending the training course compared with the total number of pupils in Year 4

21.	What is the relationship between your remote indicator and the overall aim of your programme of work? For example: Previous research has shown significant association between pedestrian skill training and safer road crossing behaviour.

22.	By how much do you hope to change the remote indicator chosen? For example: To increase the number of Year 4 children attending to 100%

23.	What is your baseline? For example: each year the training is offered to all Year 4 children in the County, approximately 900 pupils

24.	Please identify the source of your evaluation data. For example: Classroom based road safety knowledge tests

25.	What is the relationship between your impact indicator and the overall aim of your programme of work? For example: Knowledge of road risks influences pedestrian behaviour

26.	By how much do you hope to change the impact indicator chosen? For example: A 30% increase in individual road safety knowledge post-training

27.	What is your baseline? For example: Before training, Year 4 students score 40% on road safety knowledge tests

28.	Please identify the source of your evaluation data. For example: Road-side testing of construction of safe routes to cross the road

29.	By how much do you hope to change the outcome indicator chosen? For example: A 10% increase in the construction of safe routes post-training

30.	What is your baseline? For example: before training, trained and control groups both show the same level of construction of safe routes (17% for instance)

It is sometimes helpful to measure a related impact indicator to understand more about why your outcome has or has not been achieved. It can also be helpful to monitor remote indicators to identify progress towards indirect or direct outcomes. If you want to consider these other options as well as Option 3, please return to Q.19.

31.	Does your campaign consist of a single intervention or is it a programme of interventions? (please select one)
	Stand-alone intervention
	Programme of interventions

32.	Who do you hope to influence with your project? (which group of road users' behaviour do you specifically want to change?)                                                                                                           For example to raise awareness amongst HGV drivers of blind spots and left turns to reduce cyclist casualties you would influence HGV drivers to benefit cyclists. This is your target group. Please select all that apply
	Car drivers (learner)
	Car drivers (novice)
	Car drivers (experienced)
	Car drivers (all)
	Car passengers
	Motor cyclist - large machine (learner)
	Motor cyclist - large machine (novice)
	Motor cyclist - large machine (experienced)
	Motor cyclist - large machine (all)
	Motor cyclist - small machine (learner)
	Motor cyclist - small machine (novice)
	Motor cyclist - small machine (experienced)
	Motor cyclist  - small machine (all)
	Motor cyclist - all
	Pedestrians
	Cyclists
	Bus users
	Public Service Vehicle Drivers
	Horse Riders
	Business drivers (non-HGV)
	Business drivers (HGV)
	Agricultural vehicle drivers
	Fleet managers
	Taxi drivers
	Age 0-5
	Age 6-10
	Age 11-15
	Age 16-24
	Adults 25+
	All ages
	Male and Female
	Just males
	Just females

33.	Who do you hope to benefit with your project? (which group of road users' safety do you specifically want to improve?) Please select all that apply
	The same as Q.32
	Car drivers (learner)
	Car drivers (novice)
	Car drivers (experienced)
	Car drivers (all)
	Car passengers
	Motor cyclist - large machine (learner)
	Motor cyclist - large machine (novice)
	Motor cyclist - large machine (experienced)
	Motor cyclist - large machine (all)
	Motor cyclist - small machine (learner)
	Motor cyclist - small machine (novice)
	Motor cyclist - small machine (experienced)
	Motor cyclist  - small machine (all)
	Motor cyclist - all
	Pedestrians
	Cyclists
	Bus users
	Public Service Vehicle Drivers
	Horse Riders
	Business drivers (non-HGV)
	Business drivers (HGV)
	Agricultural vehicle drivers
	Fleet managers
	Taxi drivers
	Age 0-5
	Age 6-10
	Age 11-15
	Age 16-24
	Adults 25+
	All ages
	Male and Female
	Just males
	Just females

34.	How many people will be exposed to your intervention? (For example: a leaflet drop or email shot to 5000 local homes publicising older driver refresher courses)

35.	Of those, how many do you realistically expect to actively engage with the intervention? (For example: 500 driving residents out of the 5000 homes delivered to will read the leaflet and attend the refresher course)

36.	Of those actively engaged how many do you expect to influence? (For example: 90%, or 450 drivers of the 500 who attend, will alter the way they drive in one or more ways)

37.	Are you specifically aiming to influence one or more of the following behaviours? (Please select all that apply)
	Mobile phone use
	Seat belt wearing
	Child car seat use
	Drink driving
	Drug driving
	Fatigue
	Speeding
	Crossing roads on foot
	On-road cycling
	Distractions
	Other

	(Please state)

38.	What elements does your ETP campaign include? (please select all that apply)
	Large scale presentation (e.g. theatre in education)
	Poster campaign
	Leaflet campaign
	Web-based elements
	Training courses in schools
	Diversionary measure (e.g. speed awareness)
	Radio advertising
	TV advertising
	Cinema advertising
	Self-selecting training (e.g. older driver training)
	One to one advice and training
	SMS messaging
	Other

	(Please state)

39.	What is the start date of the campaign? (dd/mm/yyyy)

40.	What is the planned end date for your campaign? (dd/mm/yyyy) Leave blank if not known

Thank you for entering your data. Please press submit. If you have any queries on these questions please contact lsimkins@rospa.com