Data Collection Questionnaire

Interstate 80 (I-80), Ridge Road to US Route 30
Realignment of I-80 over the Des Plaines River
 Voluntary and Confidential

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* 1. Contact Information

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* 2. Approximately how long have you lived at this location?

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* 3. Do you:

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* 4. If you own your home, is the house at this address your primary residence?

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* 5. What is your primary mode of transportation?

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* 6. Do you use I-80 for travel?

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* 7. DISABLED means a person who has a physical or mental impairment that substantially limits one or more major life activities. How many people in your household are disabled?

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* 8. How many people in your household are over 65 years old?

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* 9. Is English the primary language spoken in your house?

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* 10. If not, what is the primary language spoken in your house?

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* 11. How many people in your household speak limited English?

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* 12. How many people live in this household (including you)?

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* 13. What races are represented in your household? check all that apply

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* 14. What ethnicities are represented in your household? check all that apply

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* 15. What is your household income?

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* 16. Please identify any benefits or difficulties that you may experience due to this improvement during and/or after construction:

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