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Trial Version Organization Commuter Transportation Survey Entry Form

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Please complete the following form. * Indicates required field.

	Step 1: Name First Name:  * (Required) Last Name:  * (Required) Middle Initial: Employee ID:  * (Required) Step 2: Home Address (Address is confidential per state law) Street #:  (No PO Boxes) Street Name: City:  * (Required) State: CA - California   Zip Code:  * (Required) (Closest Major Intersection To Your Home. Please Provide Both Intersecting Street Names.) Intersection:  * And  * (Both Required) Step 3: Contact Information Phone #: () -  * (Required) This is my:  Home Phone Number   Work Phone Number   Cell Phone Number   Email Address:  * (Required) Step 4: Work Hours and Commute Information Department: 16001 16003 16004 16005 16006 16009 16010 16011 16012 16013 16014 16015 16018 16019 16021 16023 16024 16026 16027 16028 16031 16032 16033 16034 16037 16039 16040 16041 16042 16043 16045 16046 16047 16049 16054 16055 16056 16058 16059 16061 16066 16067 16070 16072 16073 16075 16076 16077 16080 16081 16083 16084 16086 16088 16092 16096 16097 16099 160A2 160A4 160B1 160B2 160B3 160B9 1613F 16206 Other    Pay Location:   (Select your most typical method of daily commute and most typical work hours below.) Commute Mode: Bicycle Carpool Drive Alone Metrolink/Rail Motorcycle Noncommuting Public Bus Telecommute Vanpool Walk Zero Emission  * (Required) Work Start Time: 1 2 3 4 5 6 7 8 9 10 11 12 : 00 15 30 45 AM PM  * (Required) Work End Time: 1 2 3 4 5 6 7 8 9 10 11 12 : 00 15 30 45 AM PM  * (Required)  Check here if your work hours vary from day to day.    Check here if you have up to one hour flexibility in your start and leave times.   Step 5: Survey Week Commute Information Instructions: Please select a time and commute mode for each day that appears below. You should fill out the time you began work. If you were on vacation, out sick or had a regular day off during the survey week, please provide your normal scheduled time for that day. Day Date Commute Mode Time You Began Work Monday 1/14/2019 Bicycle Carpool Day Off Drive Alone Metrolink/Rail Motorcycle Noncommuting Public Bus Sick Telecommute Vacation Vanpool Walk Zero Emission Other  * 1 2 3 4 5 6 7 8 9 10 11 12 : 00 15 30 45 AM PM  * (All Required) Tuesday 1/15/2019 Bicycle Carpool Day Off Drive Alone Metrolink/Rail Motorcycle Noncommuting Public Bus Sick Telecommute Vacation Vanpool Walk Zero Emission Other  * 1 2 3 4 5 6 7 8 9 10 11 12 : 00 15 30 45 AM PM  * (All Required) Wednesday 1/16/2019 Bicycle Carpool Day Off Drive Alone Metrolink/Rail Motorcycle Noncommuting Public Bus Sick Telecommute Vacation Vanpool Walk Zero Emission Other  * 1 2 3 4 5 6 7 8 9 10 11 12 : 00 15 30 45 AM PM  * (All Required) Thursday 1/17/2019 Bicycle Carpool Day Off Drive Alone Metrolink/Rail Motorcycle Noncommuting Public Bus Sick Telecommute Vacation Vanpool Walk Zero Emission Other  * 1 2 3 4 5 6 7 8 9 10 11 12 : 00 15 30 45 AM PM  * (All Required) Friday 1/18/2019 Bicycle Carpool Day Off Drive Alone Metrolink/Rail Motorcycle Noncommuting Public Bus Sick Telecommute Vacation Vanpool Walk Zero Emission Other  * 1 2 3 4 5 6 7 8 9 10 11 12 : 00 15 30 45 AM PM  * (All Required) Step 6: Commuter Information  Yes:  Please send me a RideGuide which provides a list of commuters (Including co-workers) who live near me and are interested in sharing a ride to work. The RideGuide also provides a list of Park And Ride lot locations and information on other ridesharing options such as Metrolink/rail, vanpools and public bus. By checking yes, I understand that my name, telephone number, and/or email address will be provided to other commuters who want to carpool to work.  No:  I do not want to receive a RideGuide at this time.