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Veterans Needs Assessment 2013

OBJECTIVE
The following questionnaire has been designed to identify the life challenges, needs and barriers that Veterans face within the tri-county area. The answers provided will assist Ride Connection in its efforts to improve Veterans quality of life by enhancing their mobility options.

The questions should take you no longer than 8 minutes to complete and the answers will not be linked with your name for any purpose.

QUESTIONNAIRE
Please answer the following questions as completely and truthfully as possible.
1.You are responding as a:(Required.)
2.Your gender is?(Required.)
3.Please check your age Group?
4.Your residence is located in what zip code?
5.Are you:
6.What type of housing do you currently live in?(Required.)
7.Do you have family or friends to support you?
8.What type of transportation do you use now? (please check all that apply)
9.In an average month, how many trips (a round-trip as two trips) do you take to each of the below locations the most? (Write in the number to the places most often traveled).
10.If you had additional transportation options, how many more trips would you take per week?
(Please check one answer only)
11.Do any of the following affect your travel? (Please check all that apply)
12.Do you currently drive?
13.Do you use a mobility device, cane, walker, wheelchair, scooter or anything else to help you get around?
14.Has a lack of transportation caused you to not attend activities that you once did attend?
15.Have you ever ridden the bus or max train?
16.Do you think the bus or max can get you to where you want to go?
17.How far are you able to walk comfortably on your own?
18.Is there anything else that causes you difficulty in getting where you need to go?
19.Please make any other comments or suggestions here:
All comments provided are confidential. You may choose to disclose your name and address and/or phone number at the end of the questionnaire. If you have follow up questions, please do include your name, address and phone number so a staff member may contact you to provide further information or answer your questions.

Please call Steven Easterday at 503.528.1758 with questions you may have in regards to the questionnaire.

You, the veteran and the community will benefit from the answers provided in this questionnaire.

Please print clearly:
Name of veteran completing the questionnaire: ____________________________
Name of person completing the questionnaire: ____________________________
Address: __________________________________________________________
Home phone: _____________________Cell phone: _______________________
Date Completed: __________________

Thank you in advance, for your valued responses!


Steven Easterday
Veterans Outreach Specialist
Ride Connection
Office: 503.528.1758
Fax: 503.528.1755
seasterday@rideconnection.org