Transportation and Health Survey

* 1. What is your age?

* 2. What is your gender?

Male

Female

* 3. What is your ethnicity origin (or race)?

White

Hispanic or Latino

Black or African American

Native American or American Indian

Asian/Pacific Islander

Other (please specify)

* 4. What is your five-digit zip code?

* 5. Do you have a California Driver's License?

Yes

No

N/A

* 6. Do you own a smartphone?

Yes

No

N/A

* 7. Do you own/lease a: (please check off all that apply)

Automotive Vehicle

Bus Pass

Bicycle

N/A

* 8. How many licensed drivers are in your household?

0

1-2

3-4

4+

N/A

* 9. Do you have a primary care physician?

Yes

No

* 10. Does a family member/friend drive you to your doctor's appointments?

Yes

No

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