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My disability or health condition makes it impossible to travel when there is snow or ice on the ground.

I am not really sure if I can use fixed route buses.

I can never use fixed route buses by myself.

I can use fixed route buses if it’s someplace I go all the time.

I cannot climb stairs to get on and off fixed route buses.

I am not able to use fixed route buses because I have difficulty understanding how the bus routes/system works.

I am not able to use fixed route buses for other reasons.  Please explain:

Have you ever had training to learn how to travel around the community or on how to used fixed route buses?

Yes No

Would you like information about free training to use the fixed route buses?

Yes No

When was the last time you used fixed route buses? _________________________

If you used fixed route buses in the past and have stopped using them, why did you stop?____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

List the three (3) places you go most often and how you get there now.

Where do you go? _____________________________________________________

Address______________________________________________________________

How do you get there now?______________________________________________

Where do you go? _____________________________________________________

Page 5

Revised 6/14/07

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