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Coordinated Plan Target Populations Survey
1.
What best describes your age
Under 60 years of age
Under 65 years of age
Over 65 Years of age
2.
Do you have a disability
Yes
No
3.
Are you a Veteran?
Yes
No
4.
Do you rely on a person, not a member of your household, organization, or company, to provide transportation services?
Yes
No
5.
What is your most common destination?
Medical appointments
Grocery shopping
Social activities
Errands
Employment
Personal appointments
Other (please specify)
6.
Are you able to drive yourself when you travel?
Yes
No
7.
Are you unable to travel by yourself due to (check all the apply
Disability or health condition
I do not have a valid driver's license
I do not have access to a working vehicle
I cannot drive in the dark
Other (please specify)
8.
So you use a mobility device (like a wheelchair, service animal, or personal attendant?
Yes
No
9.
If Yes, what type?
Manual wheelchair
Motorized wheelchair
Scooter
Walker
Cane
Personal assistant
Portable Oxygen
Other (please specify)
10.
In a typical month, which of the following forms of transportation do you use? (Check all that apply)
Friend/Relative (outside of your household)
Bicycle
Van provided by your housing provider
Automobile (Personal vehicle)
Walk
Community Agency Van
Transit
Taxi/Uber/Lyft
Church program
Other (please specify)
11.
In a typical month, which of the following forms of transportation do you use MOST? (Check all that apply)
Church program
Friend/Relative (outside of your household)
Transit
Taxi/Uber/Lyft
Bicycle
Community Agency Van
Automobile (Personal vehicle)
Walk
Van provided by your housing provider
Other (please specify)
12.
Do you have difficulty leaving your home due to lack of transportation?
Yes
No
13.
Are there places that you have trouble getting to because of transportation problems? If so, please name the top three places. (For example, post office, grocery store, or medical appointments)
Place 1
Place 2
Place 3
14.
Are you aware of the following Pocatello Regional Transit Demand Response?
Yes
No
15.
Do you use Pocatello Regional Transit Door-to Door Services?
Yes
No
16.
Have you encountered any barriers in using Pocatello Regional Transit Door-to- Door Service (check all that apply)
Cost
I must plan ahead for services
The pick up or drop off windows are too large to meet my needs.
The service in not available after 7:00 pm
I cannot schedule a ride before 8:00 am or after 4:00 pm
It takes too long to get to my destination using transit
I do not like to share rides with others
Other (please specify)
17.
Are you aware of the Pocatello Regional Transit fixed route services?
Yes
No
18.
Are you able to access the Pocatello Regional Transit fixed bus routes?
Yes
No
19.
Have you encountered barriers that prevent you from using Pocatello Regional Transit fixed bus routes? (check all that apply)
I am unable to walk or get to a transit stop due to a physical limitation or disability.
The sidewalks to the transit stop are not accessible or do not exist.
I live too far from a transit stop
Transit routes do not go where I need to go.
Transit routes do not operate when I need to go
It takes too long to get to my destination using transit.
Transit stops do not have protective shelters or benches
I do not know where the bus operates
I do not know when the bus operates.
Other (please specify)