Rider Data Collection Form

Please complete this form for each bike requested. We will let you know when your bike is available for pick up.

Bike Request Information

Question Title

* Today's Date
(Please use this format: MM/DD/YYYY)

Question Title

* Name of Organization

Question Title

* Requester Name

Question Title

* Requester Email

Question Title

* Requester Phone

Bike & Rider Information
(Data will be used to support organizational impact reporting.)

Question Title

* Zip code

Question Title

* Number of people living in household
(Immediate family only)

More than 5

Not Available

Question Title

* Household income range
(Total gross income for immediate family)

Less than $10,000

$10,000 - $14,999

$15,000 - $24,999

$25,000 - $34,999

$35,000 - $49,999

$50,000 - $74,999

$75,000 - $99,999

$100,000 and over

Not Available

Question Title

* Employment status

Part-time

Full-time

Unemployed

Unknown

Question Title

* Age range

Under 15

15 - 19 years

20 - 24 years

25 - 29 years

30 - 34 years

35 - 39 years

40 - 44 years

45 - 50 years

50 and over

Not Available

Question Title

* Gender identity

Female

Male

Non-binary

Not available

Other (please specify)

Question Title

* Race/ethnicity

American Indian/Alaskan Native

Asian

Black/African American

Hispanic/Latinx

Native Hawaiian/Pacific Islander

White

Multiracial

Not available

Other (please specify)

Question Title

* Is the bike recipient a recent immigrant, migrant, or refugee?

Yes

Not available

Question Title

* If the recipient is an immigrant, migrant, or refugee, what is their country of origin?

Afghanistan

Bosnia

Congo

Mauritania

Mexico

Sudan

Ukraine

Not applicable

Not available

Other (please specify)

Bike Usage Information

Question Title

* Please identify the PRIMARY way in which the bike is planned to be used.
(Select the option that BETTER reflects the MOST COMMON WAY in which you use the bike.)

Transportation for work

Transportation for appointments (medical, mental, health, social work, etc.)

Transportation to access daily basic needs (grocery store, laundromat, pharmacy, etc.)

Use for exercise and/or mental/physical wellbeing

Transportation for educational/community education purposes

Recreational/social use

Unknown

Other (please specify)

Question Title

* How often is the bike expected to be used?
(Please select the frequency that is CLOSEST.)

Once a day

Once a week

Once every other week

Once a month

Unknown

Other (please specify)

Question Title

* What is the estimated distance for which the bike is expected to be commonly used (per trip)?

0 - 3 miles

4 - 7 miles

8 - 10 miles

11 or more miles

Unknown

Other (please specify)

Rider Data Collection Form

Question Title

* Today's Date(Please use this format: MM/DD/YYYY)

Question Title

* Name of Organization

Question Title

* Requester Name

Question Title

* Requester Email

Question Title

* Requester Phone

Question Title

* Zip code

Question Title

* Number of people living in household(Immediate family only)

Question Title

* Household income range(Total gross income for immediate family)

Question Title

* Employment status

Question Title

* Age range

Question Title

* Gender identity

Question Title

* Race/ethnicity

Question Title

* Is the bike recipient a recent immigrant, migrant, or refugee?

Question Title

* If the recipient is an immigrant, migrant, or refugee, what is their country of origin?

Question Title

* Please identify the PRIMARY way in which the bike is planned to be used.(Select the option that BETTER reflects the MOST COMMON WAY in which you use the bike.)

Question Title

* How often is the bike expected to be used?(Please select the frequency that is CLOSEST.)

Question Title

* What is the estimated distance for which the bike is expected to be commonly used (per trip)?

Question Title

* Notes(Please provide any additional information for Upcycle Bikes.)

* Today's Date
(Please use this format: MM/DD/YYYY)

* Number of people living in household
(Immediate family only)

* Household income range
(Total gross income for immediate family)

* Please identify the PRIMARY way in which the bike is planned to be used.
(Select the option that BETTER reflects the MOST COMMON WAY in which you use the bike.)

* How often is the bike expected to be used?
(Please select the frequency that is CLOSEST.)

* Notes
(Please provide any additional information for Upcycle Bikes.)