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Mail Survey
Section B
Introduction
This section of the questionnaire asks about the persons in your household.
1.(B1) Including yourself, how many people currently live in your household?
Number of people in your household |__|__|
Please count everyone, including yourself, babies, small children, and any non-relatives
who live there most of the time. Household members include people who think of this
household as their primary residence. It includes people who usually stay in the
household, but are temporarily away on business, vacation, or in a hospital.
It does not include someone just visiting, such as a college student who normally
has been living away at school.
2. (B7) How many telephone numbers are there in your household that are for regular
telephone usage?
Number of home telephone numbers |__|__|
Please exclude numbers dedicated for business use, faxes, modems, and all cell phones.
3. (B2) Thinking about the transportation system, including roads, public transportation,
bikeways and sidewalks, how satisfied are you with:
Please circle the answer that applies to you for each statement.
| a) The ease of driving or riding as a passenger in
your community |
1 |
2 |
3 |
4 |
5 |
| b) The availability of public transportation
in your community |
1 |
2 |
3 |
4 |
5 |
| c) The availability of bikeways, pedestrian
paths and sidewalks in your community |
1 |
2 |
3 |
4 |
5 |
A focus of this survey is on transportation needs of persons with disabilities.
The Americans with Disabilities Act defines a disability as a physical or mental
impairment, and these next few questions use that specific language.
4a. (B2a) Does anyone in your household have a physical or mental impairment that
causes him or her to be unable to perform a major life activity? Examples of major life
activities include seeing, hearing, speaking, caring for one's self, performing manual
tasks, walking, breathing, learning or working.
Please circle Yes or No
4b. (B2b) Other than anyone who is unable to perform these activities, does anyone
else in your household have a physical or mental impairment that significantly
restricts the conditions, manner, or duration under which he or she can perform
a particular major life activity?
Please circle Yes or No
4c. (B2c) More specifically, does anyone in your household have any of the following
long lasting conditions:
Please circle Yes or No for each question.
| a) Blindness, deafness, or a severe vision or hearing impairment?
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1 |
2 |
a1) (C5b) If anyone has a vision or hearing impairment, please indicate if this
affects vision, hearing, or both.
Please circle only one answer.
Vision - 1
Hearing - 2
Both - 3
|
Please do not write in this space |
Please do not write in this space |
| b) A condition that substantially limits one or more basic physical activities such
as walking, climbing stairs, reaching, lifting, or carrying? |
1 |
2 |
4d. (B2d) Because of a physical, mental or emotional condition lasting six months
or more, does anyone in your household have any difficulty in doing any of the
following activities:
Please circle Yes or No for each question.
| a) Learning, remembering or concentrating?
|
1 |
2 |
| b) Dressing, bathing, or getting around
inside the home? |
1 |
2 |
| c) Does anyone 16 or older have difficulty
going outside the home alone to shop or
visit a doctor's office? |
1 |
2 |
| d) Does anyone 16 or older have
difficulty working at a job or business? |
1 |
2 |
4e. (B2e) Does your household have a child who is receiving special education
services?
Please circle Yes or No
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If you answered NO to all of questions 4a, 4b, 4c, 4d and 4e, please skip now to the
box on page 7. Otherwise continue with the next questions.
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5. (B3) You indicated that some of the persons in your household have certain conditions
or difficulties. How many people have any of these conditions or difficulties?
Number of persons with disabilities |__|__|
6. (B3A) Overall, do you consider these conditions or difficulties to be mild,
moderate, or severe?
- Mild - 1
- Moderate - 2
- Severe - 3
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If there is only one person in your home with a disability, please have them complete the
remainder of this survey. If this person is a child under age 16, or is unable to
complete the survey, please complete it for them.
If there is more than one person in your home with a disability, please have the person
with the next birthday complete the remainder of this survey. If this person is a child
under age 16, or unable to complete the survey, please complete it for them.
If there is no one with a disability in your household, please complete the remainder
of this survey about yourself.
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