Facilitating Access to Coordinated Transportation (FACT)

Client Demographic Survey

*Please take a few moments to complete the following questions. Submittal of this information is voluntary. Your feedback is very important and we appreciate your participation!

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* 1. What is your sex?

Female

Male

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* 2. What is your race?

Asian/Pacific Islander

American Indian/Alaskan Native

White (not Hispanic)

African American

Hispanic

Other (please specify)

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* 3. Do you have a disability?

Yes

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* 4. What is your age?

Under 40

40-59

60-64

65-74

75 and over

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* 5. How many people live in your household?

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* 6. What is your household's total annual income?

$25,000 or less

25,001-$33,000

$33,001-$40,000

$40,001-$50,000

$50,001-$60,000

$60,001-$70,000

$70,001-$80,000

$80,001-$90,000

$90,000-$100,000

Over $100,000

Facilitating Access to Coordinated Transportation (FACT)

Client Demographic Survey

Question Title

* 1. What is your sex?

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* 2. What is your race?

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* 3. Do you have a disability?

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* 4. What is your age?

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* 5. How many people live in your household?

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* 6. What is your household's total annual income?

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* 7. What language is primarily spoken in your household?

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* 8. On average, how many times a month do you access transportation services provided by FACT?