Where do I want/need to go?
How often do I go there?
How far is it from my home?
Do I know other people that go there?
Is there another way I could get there?
Comments / notes
Grocery store
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Pharmacy
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Place of worship
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Hairdresser, hair salon, barbershop
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Bank or post office
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Work or volunteer
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Doctor’s office
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Dentist’s office
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Therapy (physical, occupational, psychological, etc.)
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Friend / family’s home or meeting place
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Restaurant, café, bar
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Gym or place of exercise (fitness center, swimming pool, YMCA,
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Library
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Senior center or social club
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Place of entertainment (movie theater, music theater, etc.)
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Local park, community garden, green area
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Vacation spot
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Visit friend in hospital or home
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Convenience store
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Other
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Other
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
Other
Times per month N/A 1 2 3 4 5 6 7 8 9 10 More than 10
Select miles 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 More than 50
Select option Yes No
Other options Bus Family/Friend Senior Shuttle Uber/Lyft/Taxi Volunteer
