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Exit Survey
 
Gender
Male Female
 
 
 
Age
Under 18 18-29 30-49 50+
 
 
 
I find it easy to put my child into the car
Strongly Disagree Disagree Neither Agree Nor Disagree Agree Strongly Agree
 
 
 
I get distracted whilst driving with my child in the car
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
 
 
 
My child gets bored whilst in the car
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
 
 
 
My child looks/ feels comfortable in the car
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
 
 
 
My child has injured themselves at home
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
 
 
 
My child has severely injured themselves at home
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
 
 
 
Where do you feel is the most riskiest place for your child around the home?
Kitchen Bedroom Bathroom Living room Other
 
 
 
 
What safety precautions do you have around the house?