Mobility and Accessibility Transportation Survey
Help us identify the needs and gaps in transportation services for Older Adults and Individuals with disabilities, including their families and caregivers.
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1.
Are you currently able to drive?
(Required.)
Yes
No
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2.
If you are able to drive, to which of the following local destinations do you drive? (Check all the apply)
(Required.)
Shopping, Grocery Store, Bank
Medical/Dental Appointments
Social Outings (To See Friends or Family, restaurant, golf, etc.)
School/Classes
Work
Religious Services
I don't drive to any destinations
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3.
If you are able to drive yourself, what challenges have you experienced during the past 3 months? (Check all that apply)
(Required.)
Unreliable car/truck; needs repairs
Cost of gas
Don’t like driving at night
No driver’s license or license suspended
Cannot afford/No car insurance
Disability or other physical/cognitive limitation that restricts driving
Don’t own a car/truck
Don’t like driving at any time
No difficulties in driving myself
Other (please Explain)
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4.
During the past 3 months, were you unable to travel to any of the following destinations because you did not have access to transportation (either your own vehicle or a ride)? (Check all that apply)
(Required.)
Grocery Shopping
Other Shopping
Religious Service
To see family/friends
Medical Appointments
Other Appointments
Pharmacy
School or Classes
Bank
None, I always have a way to get where I need to go
Other (please explain)
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5.
During the past 3 months, how often are you unable to get where you need to go because of not having a way to get there?
(Required.)
Rarely or Infrequently
Several times in the past 3 months
About once a month
More than once a month
Once a week or more often
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6.
What type of transportation have you used in the past 3 months? (Check all that apply)
(Required.)
I use my own vehicle
Medicaid Transportation
Public Transit
Office for Aging Bus
CAPCO’s Volunteer Driver Program
Walk
Bicycle
Taxi
Lyft/Uber
Rides from Friends or Family
Other (please explain)
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7.
Do you know what the CAPCO’s Volunteer Driver Program is?
(Required.)
Yes
No
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8.
During the past 3 months, what barriers to reliable transportation do you experience? (Check all that apply)
(Required.)
Cost of public transit
Cost of taxi/private transportation
Cost of gas
No driver’s license or license suspended
Lack of access to a vehicle
Not comfortable driving/cannot drive
Cannot afford/No car insurance
Public transportation not accessible
Don’t feel safe using public transportation
Don’t know how to use public transportation
Don’t have someone to drive me
Unable to afford car repairs
Disability or other physical/cognitive limitation that restricts driving
Canceled trips through Medicaid
None, I haven’t experienced any barriers during the past 3 months.
Other (please specify)
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9.
If you experience transportation barriers, how do these affect you? (Check all that apply)
(Required.)
Limits my ability to work outside the home
Limits my ability to shop for food
Can’t do errands when I need to
Can’t attend church, other religious services
Isolation/Feel alone or sad
Limits my ability to shop for household needs
Limits my ability to go to school
Can’t go to social outings
Skip or don’t schedule medical appointments
Do not have any transportation obstacles
Other (please specify)
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10.
Have you had difficulty finding a ride to a medical appointment in the past 3 months? If yes, please select all reasons that apply:
(Required.)
I need a wheelchair accessible vehicle
I don’t have enough money for public transit fare
I don’t know who to call to request a ride
My friends and family are not available to take me
There are no rides available when I call
I can’t get a ride at the time I need to go
I have to wait too long for a ride back home after my appointment
I have had no difficulty in finding a ride
Other (please specify)
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11.
How many times in the last 3 months have you had to cancel a medical appointment due to lack of transportation?
(Required.)
0
1
2
3
4
5
6 or more
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12.
What prevents you from using public transportation in your area? (Check all that apply)
(Required.)
Language Barrier
Cost/Too Expensive
It doesn’t go where I need to go
Often it is not on time
Too confusing to use
I don’t feel safe
Not within walking distance
None available to me or in my area
Bad customer service
I would be too embarrassed
No benches/shelter at the bus stop
None, I use public transportation
Other (please specify)
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13.
If you depend on others for any of your trips, who do you depend on? (Check all that apply)
(Required.)
Spouse
Children/Other relatives
Friends/Neighbors
Private Services, such as taxis
Public Transportation System (Cortland Transit)
Medicaid Transportation
CAPCO’s Volunteer Driver Program
Office for Aging Bus
Volunteers (from churches or non-profit organizations)
Other (please specify)
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14.
Over the past 3 months, how much did you rely on others for transportation?
(Required.)
Rarely or Infrequently
Several times in the past 3 months
About once a month
More than once a month
Once a week or more often
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15.
Who lives with you? (Check all that apply)
(Required.)
Spouse/partner/significant other
Children under age of 18
Adult Children 18 years or older
Parent(s) and/or parent(s)-in-law
Another adult family member
Roommate/unrelated adult
Live alone
Other (please specify)
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16.
Do you identify as a person with a disability or other physical or cognitive/intellectual limitation?
(Required.)
Yes
No
Prefer not to say
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17.
Does anyone who lives with you identify as a person with a disability or other physical or cognitive/intellectual limitation that affects their ability to drive?
(Required.)
Yes
No
Prefer not to say
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18.
How many motor vehicles (cars, vans, trucks, motorcycles) are available in your household?
(Required.)
0
1
2 or more
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19.
What is your gender?
(Required.)
Male
Female
Non-binary
Other
Prefer not to respond
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20.
What is your age?
(Required.)
Under 18
18-24
25-34
35-44
45-59
60-64
65+
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21.
What is your annual total household income?
(Required.)
Under $15,000
Between $15,000 and $24,999
Between $25,000 and $29,999
Between $30,000 and $34,999
Between $35,000 and $39,999
Between $40,000 and $49,999
$50,000 and Over
Prefer not to say
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22.
What zip code do you live in?
(Required.)
23.
Please use this space for comments or service suggestions: