I-80 Realignment

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

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address

Phone Number

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

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* 3. Do you:

Rent your home

Own your home

Other (please specify)

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

Yes

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* 5. What is your primary mode of transportation?

Car

Walk

Bike

Bus

Train

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

Yes

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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?

Yes

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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

White / Caucasian

Black / African-American

American Indian or Alaska Native

Asian

Native Hawaiian or other Pacific Islander

Other (please specify)

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

Hispanic

Latino

Non-Hispanic

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* 15. What is your household income?

Less than $12,000

Between $12,000 and $20,000

Between $20,000 and $30,000

Between $30,000 and $50,000

Between $50,000 and $80,000

Greater than $80,000

I-80 Realignment

Data Collection Questionnaire

Question Title

* 1. Contact Information

Question Title

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

Question Title

* 3. Do you:

Question Title

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

Question Title

* 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: