C O N N E C T- A B I L I T Y
Community Self-Assessment Survey
Please answer the following questions based on your knowledge of both community transportation
needs and available community transportation services.1 For each question, choose a number (from 5 to
1) that mostly closely matches your answer and insert it in the box provided.
5
Strongly Agree
4
Agree
3
2
Neutral
Disagree
1
Strongly Disagree
For each question, choose a number (from 5 to 1) that mostly closely matches
your answer and insert it in the box provided.
Transportation Needs in the Community
1. C
ommunity transportation services are fundamental to the ability of people in my community to access life-fulfilling destinations, such as medical care, school, work, shopping, faith-based and social
activities, and community activities.
Score
2. I am familiar with the transportation challenges that face the following populations in my community:
Population
Score
Military veterans
Older adults (seniors)
People with disabilities
People with limited English proficiency
People with limited income
Youth
Other populations: ________________________________________________________________________________
Community transportation: The network of publicly or privately owned transportation services providing general public or special-purpose
transportation (e.g., for people with disabilities, people with limited income) by bus, van, train, car, ferry, taxi, or a similar means in return for a
pre-established fare, no fare, or on a volunteer basis.
1
1
5
Strongly Agree
4
Agree
3
2
Neutral
Disagree
1
Strongly Disagree
For each question, choose a number (from 5 to 1) that mostly closely matches
your answer and insert it in the box provided.
3. I would rank the transportation needs of the following populations vis-à-vis other populations in my
community as follows (beginning with “1” for the group with the highest transportation need and ending with a “6” or “7,” depending on the number of groups identified)
______Military veterans
______Older adults (seniors)
______People with disabilities ______People with limited English proficiency
______People with limited income
______Youth
______Other (please specify):
Knowledge of Transportation Services
4. People in my community are aware of the following local community transportation services that are
available to all riders:
Service
Score
Human service agency transportation
Local bus
Local train
Ride-matching services
Ridesharing opportunities (carpooling, vanpooling)
Shuttle services
Taxi services
Volunteer driver services
Other services: _________________________________________________________________________________
5. Accurate information about community transportation services is available to:
Group
Score
General public
Human service agencies and nonprofits
Military veterans
People with disabilities
Older adults (seniors)
People with limited English proficiency
People with limited income
Youth
2
5
Strongly Agree
4
Agree
3
2
Neutral
Disagree
1
Strongly Disagree
For each question, choose a number (from 5 to 1) that mostly closely matches
your answer and insert it in the box provided.
6. Information about all local community transportation services is available through the following
electronic sources:
Source
Score
A human service agency website
A local government agency website
Another community website (e.g., United Way, Chamber of Commerce, community action agency)
Other electronic sources: __________________________________________________________________________
7.Information about all local community transportation services is available through the following
printed materials:
Resource
Score
Community bulletin boards
Local newspapers
Newsletters
Other resources:_______________________________________________________________________________
8. Information about all local community transportation services is available in languages in addition to
English.
Score
9. When new transportation services are started, the community is well informed about them.
Score
3
5
Strongly Agree
4
Agree
3
2
Neutral
Disagree
1
Strongly Disagree
For each question, choose a number (from 5 to 1) that mostly closely matches
your answer and insert it in the box provided.
Distribution of Transportation Information
10. The following nonprofit organizations effectively distribute information about local community transportation services:
Organization
Score
2-1-1 services
Community service organizations
(e.g., United Way, Red Cross)
Disability service organizations
(e.g., United Cerebral Palsy, Easter Seals)
Faith-based organizations
Veterans service organizations
Other organizations: ________________________________________________________________________________
11. The following publicly funded agencies effectively distribute information about local community transportation services:
Agency
Score
Agencies that serve people with limited income
Agencies that teach English language to people with
limited English proficiency
Child and adult protective services
Community action agencies
Disability service agencies
Medical services (e.g., hospital, medical centers)
Mental health agencies
Military veterans agencies
Older adult (senior) services agencies
Rehabilitation agencies
Workforce development agencies
Youth services agencies
Other agencies: ____________________________________________________________________________________
4
5
Strongly Agree
4
Agree
3
2
Neutral
Disagree
1
Strongly Disagree
For each question, choose a number (from 5 to 1) that mostly closely matches
your answer and insert it in the box provided.
12. The
following private groups effectively distribute information about local community
transportation services:
Group
Score
Employers
Employment agencies
Medical facilities (e.g., physicians’ offices, hospital,
rehabilitation centers)
Private transportation providers (e.g., taxi, limousine,
ambulance companies)
Retail stores
Other groups: __________________________________________________________________________________
13. There are people in my community who can help agency/organization staff and volunteers advise individuals on available transportation options (e.g., transportation solutions coordinators, mobility managers).
Score
Paying for Transportation
14. T
hinking specifically about military veterans, people with disabilities, older adults, people with limited
income, people with limited English proficiency, and youth, paying for community transportation services poses difficulties for approximately (circle one)...
No individuals in my community
10% of the people in my community
25% of the people in my community
50% of the people in my community
75% of the people in my community
100% of the people in my community
5
5
Strongly Agree
4
Agree
3
2
Neutral
Disagree
1
Strongly Disagree
For each question, choose a number (from 5 to 1) that mostly closely matches
your answer and insert it in the box provided.
15. Specific funding is available in my community to help the following populations afford transportation:
Population
Score
Military veterans
Older adults (seniors)
People with disabilities
People with limited English proficiency
People with limited income
Youth
Other populations: _________________________________________________________________________________
16. Information about these sources of financial assistance is widely available throughout the community.
Score
Support Services for Using Transportation
17. T
here are programs in my community that support individuals in learning how to use community
transportation services (e.g., travel orientation, travel training, bus buddy systems).
Score
18. Information about these travel instruction services is widely available throughout the community.
Score
19. Specific customer groups that may need to use these supports include:
Group
Score
Military veterans
Older adults (seniors)
People with disabilities
People with limited English proficiency
People with limited income
Youth
Other groups: __________________________________________________________________________________
6