Individual Profile

This survey will provide you with personalized transportation choices based on your answers to the following questions. Your results will be more accurate and thorough if you are able to answer as many questions as possible. Your information will not be shared with anyone or any agency without your consent, however data gathered from this survey may be used to inform transportation resources in the future.

Basic

Your zip code *

Do you have access to a smart phone? [+ What's this?]

Yes

Not Sure

Do you have access to the Internet?

Yes

Do you have access to a credit/debit card?

Yes

Do you have health insurance?

Yes

Age

Please enter your Age:

Mobility Aids

Do you require any of the following (please select all that apply):

Ability

Please answer the following questions about your travel needs:

Can you ride in a vehicle that would require you to climb a few steps to get in? *

Yes

Sometimes

Are you able to ride a bicycle, even if you don’t own one?

Yes

Sometimes

Are you able to ride a Port Authority bus?

Yes

Sometimes

Not Sure

Yes

Sometimes

Not Sure

Do you need assistance getting to the curb from whichever building you are leaving? (Home, doctor’s office, etc.)

Yes

Sometimes

Do you need assistance beyond the lobby of a public building or into a home?

Yes

Sometimes

Do you need assistance with packages/bags?

Yes

Sometimes

Do you need hand-to-hand service? [+ What's this?]

Yes

Sometimes

Do you need assistance securing your seatbelt?

Yes

Sometimes

Are you hearing impaired, or deaf?

Yes

Are you visually impaired, or blind?

Yes

Do you have any intellectual or behavioral health disabilities? [+ What's this?]

Yes

If you travel with a wheelchair, are you able to transfer from your wheelchair to the front seat of a car, independently?

Yes

N/A

Will you be traveling with another person?

Yes

Sometimes

Purpose of trip

Please indicate the trip purpose that you anticipate using the transportation services for (please select all that apply):

Medical (Examples: appointments, check-ups, dialysis, methadone clinic, pharmacy, etc.)

Work/School

Grocery shopping

Senior Center (Examples: LifeSpan, Vintage, JCC, etc.)

Entertainment (Examples: YMCA, Church, Symphony, Visiting Friends/Family, Out to Dinner, etc.)

Time of trip

Please indicate the times of day and types of days that you anticipate using transportation service (please select all that apply):

Weekdays

Saturday

Sunday

Evenings ONLY (5pm – 9pm)

Late at Night ONLY (After 9pm – Midnight)

Sort Preferences

Sort by: (Please select one of the following)

Cost

No Shared Ride

Same Day Reservation

Driver Assistance

Cost

No Shared Ride

Same Day Reservation

Driver Assistance

Remember to answer as many questions as possible!