Loudoun County Mobility Services Form

Mobility Transit Survey

Loudoun County Transit and Commuter Services has a goal to enhance mobility for the older adults and individuals with disabilities. This database will be used to link Loudoun County residents with needed transportation options. Key information that you share will be used in our database. For questions, please contact Stacey Smith, Mobility Services Coordinator at 571-367-8597, Stacey.Smith@loudoun.gov

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* 1. Organization Name:

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* 2. Contact Number

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* 3. Contact Email Address

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* 4. Contact Phone Number

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* 5. Address of the Organization

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* 6. What service type best describes what your organization offers? Choose all that apply.

On Demand

On Demand (medical)

Taxi

Other (please specify)

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* 7. What type of service does your organization offer? Select options that best describe the service(s) provided.

curb-to -curb

door-to-door

Other (please specify)

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* 8. Based on the services(s) selected in the previous question, please specify the details of the service. Choose all that apply.

	YES	NO
Do you provide services on the weekday (Monday-Friday)?	Do you provide services on the weekday (Monday-Friday)? YES	Do you provide services on the weekday (Monday-Friday)? NO
Do you provide services on Saturday?	Do you provide services on Saturday? YES	Do you provide services on Saturday? NO
Do you provide services on Sunday?	Do you provide services on Sunday? YES	Do you provide services on Sunday? NO
Do you provide services on Federal Holidays?	Do you provide services on Federal Holidays? YES	Do you provide services on Federal Holidays? NO
Do you provide services in the evening?	Do you provide services in the evening? YES	Do you provide services in the evening? NO
Do your services provide or connect to or from a Metrorail Stations?	Do your services provide or connect to or from a Metrorail Stations? YES	Do your services provide or connect to or from a Metrorail Stations? NO
Do you provide services in Western Loudoun County?	Do you provide services in Western Loudoun County? YES	Do you provide services in Western Loudoun County? NO
Do you provide services in Eastern Loudoun County?	Do you provide services in Eastern Loudoun County? YES	Do you provide services in Eastern Loudoun County? NO
Are your vehicles ADA accessible?	Are your vehicles ADA accessible? YES	Are your vehicles ADA accessible? NO
Do you provide services outside of Loudoun County?	Do you provide services outside of Loudoun County? YES	Do you provide services outside of Loudoun County? NO
Do you provide services to older adults?	Do you provide services to older adults? YES	Do you provide services to older adults? NO
Can a rider be accompanied with another passenger (i.e. personal care attendant, family member, etc.)?	Can a rider be accompanied with another passenger (i.e. personal care attendant, family member, etc.)? YES	Can a rider be accompanied with another passenger (i.e. personal care attendant, family member, etc.)? NO

Loudoun County Mobility Services Form

Mobility Transit Survey

Question Title

* 1. Organization Name:

Question Title

* 2. Contact Number

Question Title

* 3. Contact Email Address

Question Title

* 4. Contact Phone Number

Question Title

* 5. Address of the Organization

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* 6. What service type best describes what your organization offers? Choose all that apply.

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* 7. What type of service does your organization offer? Select options that best describe the service(s) provided.

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* 8. Based on the services(s) selected in the previous question, please specify the details of the service. Choose all that apply.

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* 9. Please share any additional comments.