1. 1. Location on highway (check one): ____ Points [ ] 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
2. 2. 15 minute vehicular count on roadway being walked by ____ Points the students: ____ vehicles
3. 3. Speed limit on roadway being walked: __ mph ____ Points

4. X. Total Points (Line 1 + Line 2 + Line 3) ____ Points

   HAZARD TYPE - Highway Intersections

5. 4. Traffic control on roadway being crossed ____ Points (check one): Number of lanes of traffic: ____ lanes [ ] 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 5. 15 minute vehicular count on roadway being crossed by ____ Points the students: ____ vehicles 6. Speed limit on roadway being crossed: ____ mph ____Points

6. Y. Total Points (Line 4 + Line 5 + Line 6) ____Points

   HAZARD TYPE - Highway-Railroad Grade Crossings

7. 7. a) Number of tracks crossed: ____ Points b) Number of trains daily during school crossing periods: ____

8. Z. Total Points (Line 7) ____ Points

   HAZARD TYPE - High Density of Vacant Buildings or Structures

9. 8. Exceeds the local or municipal average ____

10. XX. Total Points (Line 8) ____

    HAZARD TYPE - High Incident of Violent Crime

11. 9. Exceeds statewide average for violent crime ____

12. YY. Total Points (Line 9) ____

    FINDINGS

    Single Hazard: (Line X, Y, Z, XX or YY) ____ Points ____ Exist for children through grade ____ . ____ Does not exist for any school children. 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.

    I hereby certify that the results of the analysis are accurate and reflect traffic conditions as of this date for the location under study.

    __________ ______

    Signature of School Superintendent Date

Date: ______ Completed by: ________

Name of School to Which Qualifying

Student(s) is Walking:

Address of the School:

City: ________State: ____NY ZIP Code ____.

POINT DETERMINATION

HAZARD TYPE - Highways Without Sidewalks or Inadequate Shoulders