Grafton-Coos Regional Coordination Survey
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The Grafton-Coos Regional Coordination Council on Community Transportation is conducting this survey to learn more about transportation providers in this region.The objective of this survey is to inform efforts to enhance coordination of services among the various agencies that are providing transportation by learning about common business and operational practices.

The survey contains 20 multiple choice questions and should take about 20 minutes to complete. Answers are required to all questions and space for comments or further explanation have been provided if you would like to offer additional information.

The survey will be open for response through July 15, 2010. When you have completed the survey you will be redirected to the Grafton-Coos Regional Coordination Council website at http://www.grafton-coosrcc.org

Thank you for participating in this survey.

1. ORGANIZATION CONTACT INFORMATION: Please begin by entering information about your organization below:

ORGANIZATION CONTACT INFORMATION: Please begin by entering information about your organization below: Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

2. In which Grafton or Coos County cities and towns do you provide transportation?If you provide transports to residents throughout each of the counties, check just those boxes. If you provide service to a limited number of towns, please check all that apply

In which Grafton or Coos County cities and towns do you provide transportation?If you provide transports to residents throughout each of the counties, check just those boxes. If you provide service to a limited number of towns, please check all that apply ALL COOS COUNTY Berlin Carroll Clarksville Colebrook Columbia Dalton Dummer Errol Gorham Jefferson Lancaster Milan Northumberland Pittsburg Randolph Shelburne Stark Stewartstown Stratford Whitefield	ALL GRAFTON COUNTY Alexandria Ashland Bath Benton Bethlehem Bridgewater Bristol Campton Canaan Dorchester Easton Ellsworth Enfield Franconia Grafton Groton Hanover Haverhill Hebron Holderness	Landaff Lebanon Lincoln Lisbon Littleton Livermore Lyman Lyme Monroe Orange Orford Piermont Plymouth Rumney Sugar Hill Thornton Warren Waterville Valley Wentworth Woodstock Woodsville
OTHER (please specify)

3. Please tell us about who your organization serves with transportation in the Grafton-Coos County Region. Please check all that apply.

Please tell us about who your organization serves with transportation in the Grafton-Coos County Region. Please check all that apply. Transportation is open to the general public.

Transportation is for both our clients and the general public.

Transportation is currently only for our clients but we can integrate our clients with others or the general public.

Transportation for our clients is purchased or sub-contracted.

We cannot transport our clients with others or open it to the general public (explanation is required).

4. Does your organization transport passengers across state lines?

	Yes	No
We transport passengers across state lines, but only using non-CDL vehicles.	*Does your organization transport passengers across state lines? We transport passengers across state lines, but only using non-CDL vehicles. Yes	We transport passengers across state lines, but only using non-CDL vehicles. No
We transport passengers across state lines using volunteer-owned autos.	We transport passengers across state lines using volunteer-owned autos. Yes	We transport passengers across state lines using volunteer-owned autos. No
We transport passengers across state lines in our vehicles that comply with FMCSA/FTA regulations.	We transport passengers across state lines in our vehicles that comply with FMCSA/FTA regulations. Yes	We transport passengers across state lines in our vehicles that comply with FMCSA/FTA regulations. No
We DO NOT transport passengers across state lines.	We DO NOT transport passengers across state lines. Yes	We DO NOT transport passengers across state lines. No

Other (please specify)

5. FLEET INFORMATION 1:Please tell us about the TYPES of vehicles in your fleet:

	Check all that Apply	Vehicles are Wheelchair Accessible
Sedans/Passenger Auto (up to 7 passengers)Non-CDL	*FLEET INFORMATION 1:Please tell us about the TYPES of vehicles in your fleet: Sedans/Passenger Auto (up to 7 passengers)Non-CDL Check all that Apply	Sedans/Passenger Auto (up to 7 passengers)Non-CDL Vehicles are Wheelchair Accessible
Small Vans (8-15 passengers) Non-CDL	Small Vans (8-15 passengers) Non-CDL Check all that Apply	Small Vans (8-15 passengers) Non-CDL Vehicles are Wheelchair Accessible
Large Vans (9-10 passengers) Non-CDL	Large Vans (9-10 passengers) Non-CDL Check all that Apply	Large Vans (9-10 passengers) Non-CDL Vehicles are Wheelchair Accessible
Small Transit Bus (14-16 passengers)	Small Transit Bus (14-16 passengers) Check all that Apply	Small Transit Bus (14-16 passengers) Vehicles are Wheelchair Accessible
Medium Transit Bus (18-20 passengers)	Medium Transit Bus (18-20 passengers) Check all that Apply	Medium Transit Bus (18-20 passengers) Vehicles are Wheelchair Accessible
Large Transit Bus (20 + passengers)	Large Transit Bus (20 + passengers) Check all that Apply	Large Transit Bus (20 + passengers) Vehicles are Wheelchair Accessible
Ambulance	Ambulance Check all that Apply	Ambulance Vehicles are Wheelchair Accessible

OTHER (please specify)

6. FLEET INFORMATION 2: Please indicate the NUMBER of each vehicle type that is used in your organization. Respond with a number, not text:

FLEET INFORMATION 2: Please indicate the NUMBER of each vehicle type that is used in your organization. Respond with a number, not text: Sedans/Passenger Auto (up to 7 passengers)Non-CDL
Small Vans (8-15 passengers) Non-CDL
Large Vans (9-10 passengers) Non-CDL
Small Transit Bus (14-16 passengers)
Medium Transit Bus (18-20 passengers)
Large Transit Bus (20 + passengers)
Ambulance
TOTAL FLEET SIZE

7. FLEET INFORMATION 3: What is the SEATING CAPACITY of each type of vehicle in your fleet? Please respond with a whole number, not text:

FLEET INFORMATION 3: What is the SEATING CAPACITY of each type of vehicle in your fleet? Please respond with a whole number, not text: Sedans/Passenger Auto (up to 7 passengers)Non-CDL
Small Vans (8-15 passengers) Non-CDL
Large Vans (9-10 passengers) Non-CDL
Small Transit Bus (14-16 passengers)
Medium Transit Bus (18-20 passengers)
Large Transit Bus (20 + passengers)
Ambulance
TOTAL DAILY SEATING CAPACITY

8. Please tell us if you have an Internet connection. If you do, please choose the type of connection from the list.

Please tell us if you have an Internet connection. If you do, please choose the type of connection from the list. NOT CONNECTED TO THE INTERNET

Dial-Up Connection

DSL

Cable

Satellite

Other (please specify)

9. MANAGEMENT INFORMATION SYSTEM: Most transportation providers record some information about clients in order to provide their services. First we would like to know a little bit about how your organization is managing data. We also want to learn about the staff that work on dispatching or scheduling trips. Please tell us whether:

	YES	NO
You collect trip information electronically	*MANAGEMENT INFORMATION SYSTEM: Most transportation providers record some information about clients in order to provide their services. First we would like to know a little bit about how your organization is managing data. We also want to learn about the staff that work on dispatching or scheduling trips. Please tell us whether: You collect trip information electronically YES	You collect trip information electronically NO
You collect trip information on paper only	You collect trip information on paper only YES	You collect trip information on paper only NO
You have personnel on staff that collect this data	You have personnel on staff that collect this data YES	You have personnel on staff that collect this data NO
You have volunteers on staff that collect this data	You have volunteers on staff that collect this data YES	You have volunteers on staff that collect this data NO
You provide training to staff on scheduling or dispatching	You provide training to staff on scheduling or dispatching YES	You provide training to staff on scheduling or dispatching NO

IF YOU COLLECT THIS INFORMATION ELECTRONICALLY, PLEASE TELL US WHICH SOFTWARE PACKAGE OR OFFICE TOOL YOU ARE CURRENTLY USING:

10. DEMOGRAPHIC DATA: We would like to know more about the type of information that you collect and store in either paper files or electronic database about transports. Please indicate whether:

	YES	NO
You assign a unique customer identification number such as the last four digits of the social security number	*DEMOGRAPHIC DATA: We would like to know more about the type of information that you collect and store in either paper files or electronic database about transports. Please indicate whether: You assign a unique customer identification number such as the last four digits of the social security number YES	You assign a unique customer identification number such as the last four digits of the social security number NO
You have a method for determining the unduplicated number of individuals served	You have a method for determining the unduplicated number of individuals served YES	You have a method for determining the unduplicated number of individuals served NO
You note special needs information such as mobility device or personal care attendant in your records	You note special needs information such as mobility device or personal care attendant in your records YES	You note special needs information such as mobility device or personal care attendant in your records NO
You Record Town of Residence	You Record Town of Residence YES	You Record Town of Residence NO
You Record the Zip Code	You Record the Zip Code YES	You Record the Zip Code NO

IF YOU COLLECT THIS INFORMATION ELECTRONICALLY, PLEASE TELL US WHICH SOFTWARE PACKAGE OR OFFICE TOOL YOU ARE CURRENTLY USING:

11. TRIP PURPOSE INFORMATION:Do you collect information about the purpose of each trip? If so, do you capture general detail such as those options provided below:

	YES, WE COLLECT THIS INFORMATION	NO, WE DO NOT COLLECT THIS INFORMATION
Acute Medical including Chemotherapy or Dialysis	*TRIP PURPOSE INFORMATION:Do you collect information about the purpose of each trip? If so, do you capture general detail such as those options provided below: Acute Medical including Chemotherapy or Dialysis YES, WE COLLECT THIS INFORMATION	Acute Medical including Chemotherapy or Dialysis NO, WE DO NOT COLLECT THIS INFORMATION
General Medical	General Medical YES, WE COLLECT THIS INFORMATION	General Medical NO, WE DO NOT COLLECT THIS INFORMATION
Human Services Appointments	Human Services Appointments YES, WE COLLECT THIS INFORMATION	Human Services Appointments NO, WE DO NOT COLLECT THIS INFORMATION
Education/Training	Education/Training YES, WE COLLECT THIS INFORMATION	Education/Training NO, WE DO NOT COLLECT THIS INFORMATION
Employment	Employment YES, WE COLLECT THIS INFORMATION	Employment NO, WE DO NOT COLLECT THIS INFORMATION
Social Events	Social Events YES, WE COLLECT THIS INFORMATION	Social Events NO, WE DO NOT COLLECT THIS INFORMATION
Shopping	Shopping YES, WE COLLECT THIS INFORMATION	Shopping NO, WE DO NOT COLLECT THIS INFORMATION

OTHER (please specify)

12. MODE OF TRANSPORT:Do you track the mode or method of each transport using descriptions such as those options listed below?

	YES	NO
Volunteer Driver	*MODE OF TRANSPORT:Do you track the mode or method of each transport using descriptions such as those options listed below? Volunteer Driver YES	Volunteer Driver NO
Taxi Company	Taxi Company YES	Taxi Company NO
Fixed Route	Fixed Route YES	Fixed Route NO
Demand Response (Dial-a-Ride)	Demand Response (Dial-a-Ride) YES	Demand Response (Dial-a-Ride) NO
Ambulance Van	Ambulance Van YES	Ambulance Van NO
Ambulance	Ambulance YES	Ambulance NO

OTHER (please specify)

13. VEHICLE INFORMATION FOR BILLING:Does your agency track the type of vehicle in which individual clients are transported? Are the trip costs calculated (allocated) based on the type of vehicle used for the transport?

	YES	NO
We track the type of vehicle used:	*VEHICLE INFORMATION FOR BILLING:Does your agency track the type of vehicle in which individual clients are transported? Are the trip costs calculated (allocated) based on the type of vehicle used for the transport? We track the type of vehicle used: YES	We track the type of vehicle used: NO
We determine trip costs based on the type of vehicle used:	We determine trip costs based on the type of vehicle used: YES	We determine trip costs based on the type of vehicle used: NO
We have a trip cost allocation plan that is used to determine the costs/charges for each client:	We have a trip cost allocation plan that is used to determine the costs/charges for each client: YES	We have a trip cost allocation plan that is used to determine the costs/charges for each client: NO

OTHER (please provide any other information you feel will be helpful)

14. ORIGINATION/PICK-UP INFORMATION:Now we would like to learn more about the kind of information that is collected that might be used to determine actual travel patterns of clients and that might be used to improve coordination of trips. Do you collect the following information about the Origination/Pick-Up Location?

	YES, WE COLLECT THIS INFORMATION	NO, WE DO NOT COLLECT THIS INFORMATION
Street Address	*ORIGINATION/PICK-UP INFORMATION:Now we would like to learn more about the kind of information that is collected that might be used to determine actual travel patterns of clients and that might be used to improve coordination of trips. Do you collect the following information about the Origination/Pick-Up Location? Street Address YES, WE COLLECT THIS INFORMATION	Street Address NO, WE DO NOT COLLECT THIS INFORMATION
Town	Town YES, WE COLLECT THIS INFORMATION	Town NO, WE DO NOT COLLECT THIS INFORMATION
State	State YES, WE COLLECT THIS INFORMATION	State NO, WE DO NOT COLLECT THIS INFORMATION
Zip Code	Zip Code YES, WE COLLECT THIS INFORMATION	Zip Code NO, WE DO NOT COLLECT THIS INFORMATION
Date	Date YES, WE COLLECT THIS INFORMATION	Date NO, WE DO NOT COLLECT THIS INFORMATION
Time	Time YES, WE COLLECT THIS INFORMATION	Time NO, WE DO NOT COLLECT THIS INFORMATION

OTHER (please specify)

15. DESTINATION/DROP-OFF INFORMATION:Now we would like to learn the same thing about Drop-Off Information. Do you collect the following information about the Destination/Drop-Off Location?

	YES, WE COLLECT THIS INFORMATION	NO, WE DO NOT COLLECT THIS INFORMATION
Street Address	*DESTINATION/DROP-OFF INFORMATION:Now we would like to learn the same thing about Drop-Off Information. Do you collect the following information about the Destination/Drop-Off Location? Street Address YES, WE COLLECT THIS INFORMATION	Street Address NO, WE DO NOT COLLECT THIS INFORMATION
Town	Town YES, WE COLLECT THIS INFORMATION	Town NO, WE DO NOT COLLECT THIS INFORMATION
State	State YES, WE COLLECT THIS INFORMATION	State NO, WE DO NOT COLLECT THIS INFORMATION
Zip code	Zip code YES, WE COLLECT THIS INFORMATION	Zip code NO, WE DO NOT COLLECT THIS INFORMATION
Date	Date YES, WE COLLECT THIS INFORMATION	Date NO, WE DO NOT COLLECT THIS INFORMATION
Time	Time YES, WE COLLECT THIS INFORMATION	Time NO, WE DO NOT COLLECT THIS INFORMATION

OTHER (please specify)

16. TRIP STATUS INFORMATION:The following information is often sought to determine whether trips have been completed as scheduled or whether there are instances of community need that cannot be met with existing resources. Do you record information about trips such as the items below?

	YES, WE COLLECT THIS INFORMATION	NO, WE DO NOT COLLECT THIS INFORMATION
Trip completed as scheduled	*TRIP STATUS INFORMATION:The following information is often sought to determine whether trips have been completed as scheduled or whether there are instances of community need that cannot be met with existing resources. Do you record information about trips such as the items below? Trip completed as scheduled YES, WE COLLECT THIS INFORMATION	Trip completed as scheduled NO, WE DO NOT COLLECT THIS INFORMATION
Trip canceled	Trip canceled YES, WE COLLECT THIS INFORMATION	Trip canceled NO, WE DO NOT COLLECT THIS INFORMATION
Trip Rescheduled	Trip Rescheduled YES, WE COLLECT THIS INFORMATION	Trip Rescheduled NO, WE DO NOT COLLECT THIS INFORMATION
Reason for Cancellation(Weather, Eligibility Change)	Reason for Cancellation(Weather, Eligibility Change) YES, WE COLLECT THIS INFORMATION	Reason for Cancellation(Weather, Eligibility Change) NO, WE DO NOT COLLECT THIS INFORMATION
Client canceled/Reason	Client canceled/Reason YES, WE COLLECT THIS INFORMATION	Client canceled/Reason NO, WE DO NOT COLLECT THIS INFORMATION
Client No Show	Client No Show YES, WE COLLECT THIS INFORMATION	Client No Show NO, WE DO NOT COLLECT THIS INFORMATION
Trip Request Denied/Reason	Trip Request Denied/Reason YES, WE COLLECT THIS INFORMATION	Trip Request Denied/Reason NO, WE DO NOT COLLECT THIS INFORMATION

OTHER(please specify)

17. FUNDING SOURCES: Many agencies have multiple funding sources for the provision of transportation services. Please select all the funding sources that your agency uses to provide transportation:

	YES	NO
FTA Rural Transportation 5311	*FUNDING SOURCES: Many agencies have multiple funding sources for the provision of transportation services. Please select all the funding sources that your agency uses to provide transportation: FTA Rural Transportation 5311 YES	FTA Rural Transportation 5311 NO
FTA Elders & Persons 5310 (Funds Vehicles)	FTA Elders & Persons 5310 (Funds Vehicles) YES	FTA Elders & Persons 5310 (Funds Vehicles) NO
Title III B	Title III B YES	Title III B NO
Other FTA Program (For example:JARC or New Freedoms)	Other FTA Program (For example:JARC or New Freedoms) YES	Other FTA Program (For example:JARC or New Freedoms) NO
Medicaid	Medicaid YES	Medicaid NO
Other Department of Health & Human Services	Other Department of Health & Human Services YES	Other Department of Health & Human Services NO
Private Pay	Private Pay YES	Private Pay NO

OTHER (please specify)

18. MATCH INFORMATION: Agencies match program funds in a variety of ways. Please tell us if your organization uses the following as sources of match funding? Check all that apply.

	YES	NO
Volunteer Hours	*MATCH INFORMATION: Agencies match program funds in a variety of ways. Please tell us if your organization uses the following as sources of match funding? Check all that apply. Volunteer Hours YES	Volunteer Hours NO
In-Kind Services	In-Kind Services YES	In-Kind Services NO
Local Tax Contribution	Local Tax Contribution YES	Local Tax Contribution NO
Donations	Donations YES	Donations NO
Fares (above program revenue amount)	Fares (above program revenue amount) YES	Fares (above program revenue amount) NO
State General Funds	State General Funds YES	State General Funds NO

OTHER (please specify)

19. STAFF INFORMATION: Many transportation providers have employment and training standards for individuals who drive their clients. Please check the qualifications that apply to the type of driving staff you employ qualifications of staff and volunteers who drive for your agency:

	Background Checked	DMV Checks	Insurance Verification	Tested for Substance Abuse	Trained to Drive	Trained to Meet Special Needs
Volunteer Drivers	*STAFF INFORMATION: Many transportation providers have employment and training standards for individuals who drive their clients. Please check the qualifications that apply to the type of driving staff you employ qualifications of staff and volunteers who drive for your agency: Volunteer Drivers Background Checked	Volunteer Drivers DMV Checks	Volunteer Drivers Insurance Verification	Volunteer Drivers Tested for Substance Abuse	Volunteer Drivers Trained to Drive	Volunteer Drivers Trained to Meet Special Needs
Bus/Van Drivers We Employ	Bus/Van Drivers We Employ Background Checked	Bus/Van Drivers We Employ DMV Checks	Bus/Van Drivers We Employ Insurance Verification	Bus/Van Drivers We Employ Tested for Substance Abuse	Bus/Van Drivers We Employ Trained to Drive	Bus/Van Drivers We Employ Trained to Meet Special Needs
Bus/Van Drivers Employed by Sub-contractors	Bus/Van Drivers Employed by Sub-contractors Background Checked	Bus/Van Drivers Employed by Sub-contractors DMV Checks	Bus/Van Drivers Employed by Sub-contractors Insurance Verification	Bus/Van Drivers Employed by Sub-contractors Tested for Substance Abuse	Bus/Van Drivers Employed by Sub-contractors Trained to Drive	Bus/Van Drivers Employed by Sub-contractors Trained to Meet Special Needs

IF YOU CONDUCT SOME OTHER TYPE OF DRIVER ASSESSMENT, PLEASE EXPLAIN:

20. Please tell us a little more about the type of training that you provide for staff and volunteers. Please check all that apply to each category of driver or that you do not provide the training.

	Volunteer Drivers	Paid Staff Drivers
DO NOT PROVIDE TRAINING	*Please tell us a little more about the type of training that you provide for staff and volunteers. Please check all that apply to each category of driver or that you do not provide the training. DO NOT PROVIDE TRAINING Volunteer Drivers	DO NOT PROVIDE TRAINING Paid Staff Drivers
Basic First Aid	Basic First Aid Volunteer Drivers	Basic First Aid Paid Staff Drivers
Blood Borne Pathogen Protections	Blood Borne Pathogen Protections Volunteer Drivers	Blood Borne Pathogen Protections Paid Staff Drivers
Body Mechanics and Ergonomics	Body Mechanics and Ergonomics Volunteer Drivers	Body Mechanics and Ergonomics Paid Staff Drivers
Defensive Driving	Defensive Driving Volunteer Drivers	Defensive Driving Paid Staff Drivers
Emergency Evacuation	Emergency Evacuation Volunteer Drivers	Emergency Evacuation Paid Staff Drivers
Passenger Assistance	Passenger Assistance Volunteer Drivers	Passenger Assistance Paid Staff Drivers
Incident/Accident Protocols	Incident/Accident Protocols Volunteer Drivers	Incident/Accident Protocols Paid Staff Drivers

IF THE DRIVER TRAINING THAT YOU PROVIDE IS NOT LISTED ABOVE, PLEASE EXPLAIN YOUR TRAINING:

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