For House Hold Interview Survey Questionnaire for Respondents
LGU HAMTIC
1. Name (optional)
First Name
Last Name
2. Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
3. Destination Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
4. Age
*
4.b Gender
*
Please Select
Male
Female
unknown
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4.c Total No. of members of the household, including stay in drivers
*
4.d No. of Senior Citizen in the Household
*
4.e No. of Children not of school age
*
4.f No. of Children going to school
*
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5. Civil Status
*
Single
Married
Separated
Widower
Single Parent
Rather not say
6. During WEEKDAYS, what is the usual purpose of your trip
*
Going to work
Mosque/Church
Going to School
Shopping/Market
Recreation/Park
Other
7. What time do you usually leave the house in your daily travel
*
Hour Minutes
AM
PM
AM/PM Option
8. What time do you usually arrive in your destination/workplace
*
Hour Minutes
AM
PM
AM/PM Option
9. What is your total travel time (Minutes) from home to your destination/workplace
*
in Minutes
10. Does your job/trip allow you to be flexible with your schedule in going to your destination/office/workplace/school/others?
*
yes
no
not sure
11. What is your usual primary mode of transport when you travel to your destination?
*
Please Select
Own vehicle
Own motorcycle
Tricycle
Walking
Trisikad
Jeepney
Van/FX/Shuttle
Habal-habal
Bus
Multicab
11.b Please Specify if not in the choices
12.a If you use public transport, how much is your usual fare? ________ in Pesos
answer in Pesos
12.b If you use your own vehicle, how much is the estimated cost of fuel/gas? ________ in Pesos
answer in Pesos
13. If you own a vehicle/motorcycle, what kind of vehicle? (please check all that applicable)
Car
SUV
Pickup
Jeep
Motorcycle
Other
13.c Do you have a Driver's License
*
Yes
No
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14. Do you use an access mode from your house/origin to the jeepney/bus stop/terminal?
*
NO i walk only
Jeepney
Trisikad
Own Motorcycle
Own Vehicle
Tricycle
Bus
14.b Estimated access time
please answer in minutes
14.c Cost of fare/gas: PHP
Please Answer in Peso
15. Do you use an egress mode from your last stop going to your end destination?
*
No, I walk only
Tricycle
Jeepney
Van/Shuttle
Own Motorcycle
Own Vehicle
Bus
15.b Estimated egress time
please answer in minutes
15.c Cost of fare/gas
Please answer in Peso
16. Have you ever experienced using other modes in this travel?
*
No
Yes (please answer follow up questions)
16.b Do you use tricycle?
Tricycle
No
Enter Access time (in minutes)
leave blank if you answered no on question 16.b
Enter Cost of fare/gas (in PhP)
leave blank if you answered no on question 16
Egress Travel time
Leave blank if none
Egress cost of fare/gas
Leave blank if none
16.c Do you use Jeepney?
Jeepney
No
Enter Access time (in minutes)
leave blank if you answered no on question 16.c
Enter Cost of fare/gas (in PhP)
leave blank if you answered no on question 16.c
Egress Travel time
Leave blank if none
Egress cost of fare/gas
Leave blank if none
16.d Do you use Van/Shuttle?
Van/Shuttle
No
Enter Access time (in minutes)
leave blank if you answered no on question 16.d
Enter Cost of fare/gas (in PhP)
leave blank if you answered no on question 16.d
Egress Travel time
Leave blank if none
Egress cost of fare/gas
Leave blank if none
16.e Do you use your own Motorcycle?
My own Motorcycle
No
Enter Access time (in minutes)
leave blank if you answered no on question 16.e
Enter Cost of fare/gas (in PhP)
leave blank if you answered no on question 16.e
Egress Travel time
Leave blank if none
Egress cost of fare/gas
Leave blank if none
16.f Do you use your own vehicle?
My own vehicle
No
Enter Access time (in minutes)
leave blank if you answered no on question 16.f
Enter Cost of fare/gas (in PhP)
leave blank if you answered no on question 16.f
Egress Travel time
Leave blank if none
Egress cost of fare/gas
Leave blank if none
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17.a Total number of four-wheeled vehicles in the household
17.b Total number of motorcycle vehicles in the household
18. Please provide your estimated personal monthly income
*
less than P2,500
P2,501-P5,000
P5,000-P7,500
P7,501-P10,000
P10,001-P15,000
P15,001-P20,000
P20,001-P25,000
P25,001-P30,000
P30,001-P40,000
P40,001-P50,000
P50,000-P75,000
P75,001-P100,000
P100,001-P150,000
P150,000 and above
20. Do you receive any financial support from relatives abroad? If Yes, Please provide estimate per month (In peso)
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In your best knowledge, please list down all the members of the household and who leave the house in the morning and their travel characteristic
leave blank if Not Available
Household number 1. Name / relation
leave blank if Not Available
Household number 1. Trip purpose
leave blank if Not Available
Household number 1. time leave
leave blank if Not Available Minutes
AM
PM
AM/PM Option
Household number 1. Name of Destination/location
leave blank if Not Available
Household number 1. Primary mode
leave blank if Not Available
Household number 1. Estimated travel time (Minutes)
please answer in minutes
Household number 1. Estimated Cost of travel
please answer in peso
Household number 1. Estimated Income per Month
leave blank if Not Available
Household number 2. Name / relation
leave blank if not available
Household number 2. Trip purpose
leave blank if not available
Household number 2. time leave
leave blank if not available Minutes
AM
PM
AM/PM Option
Household number 2. Name of Destination/location
leave blank if not available
Household number 2. Primary mode
leave blank if not available
Household number 2. Estimated Cost of travel
leave blank if not available
Household number 2. Estimated travel time (Minutes)
please answer in minutes
Household number 2. Estimated Cost of travel
please answer in peso
Household number 2. Estimated Income per month
please answer in peso
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Input your numbers here
separate your numbers with comma ","
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