Paratransit Survey Form

Paratransit Customer Service Survey Form

Please fill in all items on form completely and accurately.

SECTION I - IDENTIFYING INFORMATION

Last Name *

First Name *

Telephone Number *

Apartment Number

Home Street Address *

City *

Type of Home Address	House Apartment Nursing Facility ACLF Boarding House

Email Address:

Zip Code *

OPTIONAL QUESTIONS

Date of Birth (Optional)

Gender (Optional)	Male Female

Your Current Age (Optional)

Your Race (Optional)	White Black Hispanic Native American Asian Other

SECTION II - QUESTIONNAIRE

If you called to make a reservation, was the telephone answered within three rings?	Yes No

Was the reservationist pleasant and did he or she treat you with courtesy?	Yes No

Did your vehicle arrive for you on time?	Yes No

Was your vehicle clean and sanitary?	Yes No

Was your driver professionally dressed?	Yes No

Did your driver greet you by name?	Yes No

If needed, did your driver give you assistance in getting into the vehicle or to the door?	Yes No

Was your wheelchair tied down and anchored securely to the floor?	Yes No

Did you get to your destination safely and on time?	Yes No

Was your ride comfortable?	Yes No

Was your vehicle air conditioned?	Yes No

Any other comments or suggestions?