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E-Bike Lending to Ownership Program Participant Questionnaire
Northeast Transportation Connections
Thank you for your interest in NETC’s E-Bike Ownership Program. This program is designed to help residents and workers access reliable transportation.
1.
Full Name
2.
Phone Number
3.
Email
4.
Preferred way to be contacted:
Phone
Text
Email
5.
What is your address?
6.
What would you mainly use your E Bike for?
Getting to work
Getting to school
Grocery trips
Medical appointments
Childcare or family responsibilities
Connecting to transit
Running errands
7.
How do you currently get around most often?
Drive my car
Carpool
Bus or train
Walk
Personal bike or scooter
Veo (Bike share / Scooter share)
Uber/ Lyft
I don't have reliable transportation
Other (please specify)
8.
What transportation challenges are you currently facing?
Too expensive
No access to a car
Bus / train doesn't work for for my schedule
Commute too long
I have trouble getting to work /appointments on time
I dont feel safe walking / biking in some area
Other (please specify)
9.
About how far is your typical one way trip?
10.
About how much do you currently spend on transportation each month? (including gas, car payments, insurance Uber / Lyft, parking etc.)
11.
Would regular access to an e bike help you reduce transportation costs or improve your ability to get around?
Yes
No
Not Sure
Please briefly explain:
12.
Are you comfortable learning how to safely ride and care for an e bike? Training and support will be provided
Yes
No
I would like more information first
13.
Are you willing to use the e bike regularly for transportation?
Yes
No
Not Sure
14.
Are you willing to complete regular check ins with NETC? Check-ins may include mileage updates, how the bike is being used, bike condition, maintenance needs, and general feedback.
Yes
No
I would like more information
15.
Are you willing to participate in basic program reporting?
This may include short surveys, mileage updates, and sharing general information about how the e-bike is helping with transportation.
Yes
No
I would like more information
16.
This program is designed for income-qualified participants. Do you currently participate in any of the following programs, or could you provide basic income documentation if selected?
Check all that apply.
Medicaid
SNAP
Free or reduced lunch
Other public assistance
I am not sure
I prefer to discuss directly
17.
Why are you interested in this program?
Please briefly explain how an e-bike could help you with transportation.
18.
How did you hear about this program?
Please briefly explain
