Date: ______ Completed by: ________
Name of School to Which
Qualifying Student(s) is Walking: ______________________________________________________
Address of the School: ______________________________________________________
City: ________State: ____NY ZIP Code ____.
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POINT DETERMINATION
HAZARD TYPE - Highways Without Sidewalks or Inadequate Shoulders
[ ] on shoulder >= five feet wide or sidewalk
[ ] on shoulder <= five feet wide without a sidewalk
[ ] on roadway with no shoulder
[ ] on roadway at a narrow bridge or overpass
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HAZARD TYPE - Highway Intersections
[ ] no control
[ ] stop sign or traffic signal w/o ped walk lights
[ ] traffic signal with ped walk lights
[ ] all way stop signs, adult crossing guard, or pedestrian overpass/underpass
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HAZARD TYPE - Highway-Railroad Grade Crossings
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HAZARD TYPE - High Density of Vacant Bulidings or Structures.
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XX. Total Points (Line 8) ______
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HAZARD TYPE - High Incident of Violent Crime
YY. Total Points (Line 9) ______
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FINDINGS
Single Hazard: (Line X, Y, Z, XX or YY) ____ Points
____ Exist for children through grade ____.
____ Does not exist for any school children.
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________________________________________________________________
Combination of Hazards: (Line X, Y, Z, XX or YY) ____ Points (Sum of Two Greatest Hazards) ____ Exist for children through grade ____ . ____ Does not exist for any school children.........................................................
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I hereby certify that the results of the analysis are accurate and reflect traffic conditions as of this date for the location under study.
___________
Date
___________________________
Signature of School Superintendent.
N.Y. Comp. Codes R. & Regs. Tit. 17 § 191.8