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Region 3 Community Transportation Survey
For the counties of Bureau, Putnam, Lee, Ogle, Dekalb, LaSalle, Kendall, and Grundy
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* Indicates required question
Date:
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MM
/
DD
/
YYYY
County name:
*
Your answer
Do you or members of your household have access to (and can afford) a car or other vehicle that is running, licensed, and insured?
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Yes
No
Are there trips you or members of your household can't make because of a lack of transportation?
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Yes
No
If yes, what kind of trips: (Check all that apply)
Work
Medical appointments
Visiting friends or family
Shopping
Social / Entertainment
School
Kids activities (pool, park, skating, etc.)
Senior nutrition or day center
Other Agency Appointments
Religious
Other
How do you or members of your household travel now? (check all that apply)
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Drive or ride in household member's vehicle
Drive or ride in someone else's vehicle (other than a household member's)
Walk, bike, use wheelchair, etc.
Church or social service agency vehicle
Public transportation
Other:
Required
Do you or members of your household currently use public transportation?
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Yes
No
If yes, what types of transportation do you or members of your household use? (check all that apply)
Bus
Taxi
Van
Other:
Would you or members of your household use public transportation if it was available?
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Yes
No
If available, what types of transportation would you or members of your household use? (Check all that apply)
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Bus
Taxi
Van
Other
Required
If available, how would you or members of your household prefer to get a ride? (check all that apply)
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Catch a bus at a bus stop
Call ahead for a ride (curb-to-curb demand response service)
Call ahead for a ride (door-to-door demand response service for seniors or people with disabillities
N/A
Other:
Required
Please list locations (city/town names) that you or members of your household would travel to using public transportation. Write N/A if not applicable.
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Your answer
Using public transportation, how often would you or members of your household travel to the communities listed above? (Circle all that apply)
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Daily
Weekly
Monthly
N/A
What times would you or members of your household need public transportation? (check all that apply)
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Weekdays, before 7:00 AM
Weekdays, 7:00 AM to 5:00 PM
Weekdays, 5:00 PM to 10:00 PM
Weekdays, after 10:00 PM
Weekends, 7:00 AM to 5:00 PM
Weekends, 5:00 PM to 10:00 PM
Weekends, other times
Holidays
Required
How much would you or members of your household be willing to pay for a one-way trip within your county? (choose one)
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Less than $1.00
$1.00
$2.00
$3.00
$4.00
$5.00
$6.00 or more
Required
What would you change about your household's experience with public transportation and why?
*
Your answer
What is your zip code?
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Your answer
In what age range do you belong? (Circle one)
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under 20
20 - 29
30 - 39
40 - 49
50 -- 59
60 - 69
70 - 79
80 and over
How many people live in your household? (choose one)
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1
2
3
4+
Required
Does anyone in your household have a disability (physical, mental, etc.) which limits the ability to drive?
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Yes
No
If yes, how many people? Write N/A if not applicable.
Your answer
Do any of your household members need transportation to medical appointments outside the county?
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Yes
No
If yes, what city / county?
Your answer
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