Instructions
We invite you to follow these short instructions. Be aware that some questions may require
an elaborated answer which needs more time.
1. Before filling in the questionnaire, please read the questions carefully.
2. Locate all relevant documents and material on your active mobility measure which
may be available in your national language.
3. Translate into English the text you wish to submit.
4. Address each question paying attention to answer all parts of it, as this will be the
basis for evaluation.
5. 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, [email protected], +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
Free text (max 500 words)
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).
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 bike sharing)
Public transport use
Other (e.g. bike & ride, car-sharing,
skateboarding, etc.)
All non-motorised modes
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Q3.3
Free text (max 250 words)
What is your target population
and the level of action (i.e.
neighbourhood, city, regional,
national)?
Q3.4
Free text (max 500 words)
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.
4. Active mobility measure: Description
Q4.1
Title
Please tell us your active
mobility measure’s name/title.
Q4.2
Free text (max 500 words)
Describe your measure,
including implementation
timeframe, financing method
and costs.
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Q4.3
Free text with examples (max 500 words)
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.
Q4.4
Free text with examples (max 500 words)
What specific social, physical
and environmental
circumstances have
contributed to success?
Or what circumstances have
hampered your active mobility
measure implementation?
Q4.5
Free text with examples (max 500 words)
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, healthenhancing physical activity
outcomes)?
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.
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6. Health Economic Assessment Tool (HEAT)
Q6.1
Yes
Do you know the Health
Economic Assessment Tool
(HEAT) developed by the World
Health Organisation?
No
Q6.2
Free text with examples (max 250 words)
Have your city used HEAT to
assess your active mobility
measure?
Many thanks!!
To return the form with any supporting documentation, please send to Dr. Florinda Boschetti,
Polis, [email protected]
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