Questions About You Step 1 of 3 - Contact and Demographic Information 0% Email Address * Required What is your gender? * Required Female Male Other What is your age? * Required 18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75-84 years 85+ years Are you in a long-term relationship? * Required Yes No How many people live in your household (including you)? * RequiredDo any children age 18 or under live in your household? * Required Yes No How many children under the age of 18 live in your household?What are the ages of the children living in your household Enter ages separated by commas (ex. 2, 7, 14)Does anyone over the age of 65 live in your household? * Required Yes No How many people over the age of 65 live in your household?What is the highest level of school you have completed? * Required Less than high school degree High school degree or equivalent (e.g., GED) Some college but no degree Associate's degree Bachelor's degree Graduate degree Please specify your ethnicity. * Required White Asian or Pacific Islander Black or African American Hispanic or Latino Native American or American Indian What is your employment status? (check all that apply) * Required Employed Full-Time Employed Part-Time Self-employed Unemployed and looking for work Unemployed and not looking for work Homemaker Retired Student Unable to work Which days of the week do you work or attend school? (check all that apply; leave blank if this doesn't apply to you) Sunday Monday Tuesday Wednesday Thursday Friday Saturday What was your total household income before taxes during the past 12 months? * Required Less than $25,000 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 to $149,999 $150,000 or more What is your home zip code? * Required Are you Deaf or do you have difficulty with hearing? * Required Yes No Do you have a hearing aid? Yes No Are you blind or do you have difficulty seeing even when wearing glasses? * Required Yes No Do you use any of these aids? (check all that apply) Long cane Identification cane Support cane Miniguide Guide dog Because of a physical, mental, or emotional disability, do you have a hard time concentrating, remembering, or making decisions? * Required Yes No Do you have difficulty walking or climbing stairs? * Required Yes No Do you use any of these mobility devices? (Check all that apply) Powered wheelchair Manual wheelchair Walker Forearm crutches Cane Crutches Other What is the other mobility device you use? Do you require assistance for bathing or dressing? * Required Yes No Because of a physical, mental, or emotional condition, do you have a hard time traveling alone? * Required Yes No Because of a communication disability, do you have a hard time traveling alone? * Required Yes No Do you have a disability not described here? * Required Yes No Please describe the disability.If you answered yes to any of the above questions, is your disability temporary or permanent? * Required Temporary Permanent N/A Which modes of transportation do you use most frequently for routine travel? (Check all that apply) * Required Walk Wheelchair Bus Subway Train Car Taxi (or other vehicle for hire) Access-A-Ride Bicycle Other What is the other mode of transportation? Who do you travel with most frequently during your routine trips? * Required I travel alone Partner Child or children Mother Father Other family member(s) Friend(s) Coworker(s) or colleague(s) Pet(s) Other Who is the other companion you travel with during routine trips? Do you typically experience transportation challenges? * Required Yes No Which mode of transportation presents the most challenges? Walking Wheelchair Bus Subway Train Car Taxi (or other vehicle for hire) Access-A-Ride Bicycle Other What is the other mode of transportation that presents the most challenges? How do you typically deal with these challenges?On average, how much time per day is spent dealing with these challenges? Do you have anything else to add about these transportation challenges?NameThis field is for validation purposes and should be left unchanged.
