Intercity Bus Travel Survey Form

  SURVEY NUMBER     (Enter the number from the TOP LEFT Corner of the form. REQUIRED )

1.  Where are you coming from?  (Give full street address, nearest street intersection, name of company or building)

   Address        

   Community      State  

   Country        

2.  Where are you going to?  (Give full street address, nearest street intersection, name of company or building)

     Address      

     Community     State 

     Country        

3.  Describe the place you are coming from:                  01 Home02 Place of Work03 Work-connected business04 Shopping05 Personal business, medical/dental06 School07 Social/recreational08 Other

     IF OTHER, Please Specify                                        

4. Describe the place you are going to:                         01 Home02 Place of Work03 Work-connected business04 Shopping05 Personal business, medical/dental06 School07 Social/recreational08 Other   

    IF OTHER, Please Specify                                        

5. How did you get to the bus station ?          1.  Vehicle Driver2.  Vehicle Passenger3.  Taxicab4.  Hotel Courtesy Vehicle5.  Local City Bus6.  Intercity Bus7.  Walk or Bicycle8.  Other

    IF OTHER, Please Specify                          

 6.  Is this part of a roundtrip ?                                    Yes No

 7.  What fare did you pay for this trip ?                       

 8.  How often do you typically make this trip ?              1. Less than 1 round trip per month2. 1 to 4 round trips per month3. 5 to 9 round trips per month4. 10 to 19 round trips per month5. 20 or more round trips per month

 9.  What time did your bus depart ?                            

10.  What bus company are you traveling with ?                                 

11.  What is your gender ?                                            Male  Female

12.  What is your age ?                                                1. 15 or under2. 16 - 243. 25 - 344. 35 - 445. 45 - 546. 55 - 647. 65 and over

13.  If different from the addresses listed above, what is you home address ? (Give full street address or nearest street intersection)

     Address      

     Community     State 

     Country        

14. What was the combined yearly income for your household in 2010 ? (Optional)               0. No Answer1. Under $10,0002. $10,000 - $19,9993. $20,000 - $29,9994. $30,000 - $39,9995. $40,000 - $49,9996. $50,000 - $74,9997. $75,000 - $99,9998. $100,000 - $149,9999. $150,000 - $199,99910. $200,000 or Over

Thank you.

Thank you for your cooperation.

Return to Intercity Bus Survey Form