This is a sample questionnaire to determine transportation needs for seniors in suburban areas.
Please answer the following questions to help us plan for future transportation services. Name, address, and phone number are OPTIONAL.
- Do you own and drive a car?______Yes______No (If no, skip to question #4)
- If you do own and drive a car, how frequently do you use it?
_____Once or more each day
_____Two or three times each week
_____Once a week or less
_____Rarely
a
- If you do own and drive a car, please indicate your interest in using shuttle bus services if they existed in your community.
_____Very Likely
_____ Likely
_____Maybe
_____Not Likely
_____Not Interested
a
- If you do NOT own or drive a car, what is your primarily means of transportation?
_____Public transit services
_____Friends or family
_____Van services provided senior service centers
_____Walking
_____Other (Please specify)_________________________________________
a
- What are your typical destinations and how frequently do you travel to them?
Frequency
(once a day, twice a week, etc.)
_____Supermarket ________________________________________
_____Visit family/friends ________________________________________
_____Church services ________________________________________
_____Medical appointments _______________________________________
_____Social activities ________________________________________
_____Other (Please specify) ________________________________________
_______________________________________
- Please add additional information you think is important to help us determine transportation needs for seniors.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
OPTIONAL
Name____________________________________________________________
Street____________________________________________________________
City__________________________________________________ZIP________
Phone ____________________________________________________________
Thank you for your assistance in this survey. Please return it in the enclosed self-addressed, stamped envelope or drop it off at participating senior centers.