Transportation Needs - Public Consumer Survey

Please complete and submit by July 10, 2017

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* 1. Mark ALL of the transportation you or your family have used during the past 12 months to travel to work/appointments/shopping/social activities/etc: (check all that apply)

Personal vehicle

Ride with a friend/family member

Carpool or vanpool

Human services/senior agency vans

RTA

Private inter-city bus (Greyhound, GoBus, etc.)

Private taxi (Uber, Lyft, Liberty Mobility, Black & White Cab, etc.)

Faith-based organization (such as a church bus or van to go to services or activities)

Bicycle or walk (other than for exercise)

Volunteer transportation

Other (please specify)

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* 2. What changes could be made to your local transportation options to make using them more useful to you? (check all that apply)

Wheelchair accessible vehicles

Lower cost to ride

Start earlier in the morning

End later at night

Operate on Saturdays

Operate on Sundays

No shared rides with others

If vehicles operate on a fixed route/schedule with bus stops

Smaller vehicles

Larger vehicles

More reliable/on-time for picking me up/dropping me off

If you could ride to other parts of the state (such as Columbus)

Other (please specify)

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* 3. Which of the following are your most commonly visited destinations or places you most often need to visit when transportation is available to you? (check all that apply)

My employer

Clinics or Hospitals

Dialysis

Medical / Dental offices

Shopping/Grocery/Pharmacy

School

Senior program or human service agency activities and appointments

Social/Recreation activities/parks

Church/Faith-based organizations and activities

Family functions

Other (please specify)

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* 4. Do you or a family member need transportation outside of the county in which you live, but sometimes or never have it?

Yes

No

If yes, how often do you need it and to what city/town?

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* 5. How old are you?

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* 6. I am . . .

Male

Female

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* 7. Is English your first language?

Yes

No

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* 8. In what city/town do you live (or city/town nearest your home)?

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* 9. In what county do you live?

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* 10. How many children under the age of 18 live in your household?

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* 11. Including you, how many people live in your home?

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* 12. Do you have a valid driver’s license?

Yes

No

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* 13. How many licensed drivers live with you?

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* 14. Do you have a car?

Yes

No

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* 15. How many vehicles are available in your household?

0

1

2

3+

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* 16. Which of the following BEST applies to you? Are you presently:

Employed outside the home

Employed in your home

Homemaker

Disabled

Student

Retired

Not employed

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* 17. If you work outside your home, who is your employer?

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* 18. What is the city/town or county in which your employer is located?

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* 19. Do you have a disability which requires you to use a cane, walker, wheelchair, and/or another device to help you get around?

Yes

No

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* 20. Are you on Medicaid?

Yes

No

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* 21. Do you use Medicaid transportation services?

Yes

No

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* 22. Do you need wheelchair accessible transportation services?

Yes

No

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* 23. Personally, when do you need transportation most often for each of the following general purposes? (check all that apply)

	Medical/Health Care	Nutrition	Employment	Shopping	Recreational/Social	Religious
12 am - 6 am	12 am - 6 am Medical/Health Care	12 am - 6 am Nutrition	12 am - 6 am Employment	12 am - 6 am Shopping	12 am - 6 am Recreational/Social	12 am - 6 am Religious
6 am - 8 am	6 am - 8 am Medical/Health Care	6 am - 8 am Nutrition	6 am - 8 am Employment	6 am - 8 am Shopping	6 am - 8 am Recreational/Social	6 am - 8 am Religious
8 am - 12 pm	8 am - 12 pm Medical/Health Care	8 am - 12 pm Nutrition	8 am - 12 pm Employment	8 am - 12 pm Shopping	8 am - 12 pm Recreational/Social	8 am - 12 pm Religious
12 pm - 3 pm	12 pm - 3 pm Medical/Health Care	12 pm - 3 pm Nutrition	12 pm - 3 pm Employment	12 pm - 3 pm Shopping	12 pm - 3 pm Recreational/Social	12 pm - 3 pm Religious
3 pm - 6 pm	3 pm - 6 pm Medical/Health Care	3 pm - 6 pm Nutrition	3 pm - 6 pm Employment	3 pm - 6 pm Shopping	3 pm - 6 pm Recreational/Social	3 pm - 6 pm Religious
6 pm - 9 pm	6 pm - 9 pm Medical/Health Care	6 pm - 9 pm Nutrition	6 pm - 9 pm Employment	6 pm - 9 pm Shopping	6 pm - 9 pm Recreational/Social	6 pm - 9 pm Religious
9 pm - 12 am	9 pm - 12 am Medical/Health Care	9 pm - 12 am Nutrition	9 pm - 12 am Employment	9 pm - 12 am Shopping	9 pm - 12 am Recreational/Social	9 pm - 12 am Religious

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* 24. In the last month, how often have you...

	Never (0 times)	Sometimes (1-2 times)	Frequently (3-4 times)	Almost Always (5+ times)
Missed a medical appointment IN your community because you did not have a ride?	Missed a medical appointment IN your community because you did not have a ride? Never (0 times)	Missed a medical appointment IN your community because you did not have a ride? Sometimes (1-2 times)	Missed a medical appointment IN your community because you did not have a ride? Frequently (3-4 times)	Missed a medical appointment IN your community because you did not have a ride? Almost Always (5+ times)
Missed a medical appointment OUTSIDE your community because you did not have a ride?	Missed a medical appointment OUTSIDE your community because you did not have a ride? Never (0 times)	Missed a medical appointment OUTSIDE your community because you did not have a ride? Sometimes (1-2 times)	Missed a medical appointment OUTSIDE your community because you did not have a ride? Frequently (3-4 times)	Missed a medical appointment OUTSIDE your community because you did not have a ride? Almost Always (5+ times)
Have you been unable to shop for GROCERIES because you did not have a ride?	Have you been unable to shop for GROCERIES because you did not have a ride? Never (0 times)	Have you been unable to shop for GROCERIES because you did not have a ride? Sometimes (1-2 times)	Have you been unable to shop for GROCERIES because you did not have a ride? Frequently (3-4 times)	Have you been unable to shop for GROCERIES because you did not have a ride? Almost Always (5+ times)
Have you been unable to get together with FAMILY because you did not have a ride?	Have you been unable to get together with FAMILY because you did not have a ride? Never (0 times)	Have you been unable to get together with FAMILY because you did not have a ride? Sometimes (1-2 times)	Have you been unable to get together with FAMILY because you did not have a ride? Frequently (3-4 times)	Have you been unable to get together with FAMILY because you did not have a ride? Almost Always (5+ times)
Have you been unable to attend SOCIAL FUNCTIONS because you did not have a ride?	Have you been unable to attend SOCIAL FUNCTIONS because you did not have a ride? Never (0 times)	Have you been unable to attend SOCIAL FUNCTIONS because you did not have a ride? Sometimes (1-2 times)	Have you been unable to attend SOCIAL FUNCTIONS because you did not have a ride? Frequently (3-4 times)	Have you been unable to attend SOCIAL FUNCTIONS because you did not have a ride? Almost Always (5+ times)
Have you been unable to go to a RELIGIOUS activity because you did not have a ride?	Have you been unable to go to a RELIGIOUS activity because you did not have a ride? Never (0 times)	Have you been unable to go to a RELIGIOUS activity because you did not have a ride? Sometimes (1-2 times)	Have you been unable to go to a RELIGIOUS activity because you did not have a ride? Frequently (3-4 times)	Have you been unable to go to a RELIGIOUS activity because you did not have a ride? Almost Always (5+ times)

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* 25. Please provide your name and address