Exit this survey Gas Accessibility Survey 2011 The National MS Society, Greater Illinois and Gateway Area Chapters are seeking information from you about your experience in obtaining assistance with refueling at gas stations. We will collect and summarize aggregate data that will be used to strengthen the case for improving gas station accessibility in Illinois. Question Title * 1. What is your gender? Male Female Question Title * 2. What is your age? 21-25 26-35 36-45 46-55 Over 55 Question Title * 3. What is your disability? Cognitive Mobility Visual Hearing/Speech Other Question Title * 4. How often do you drive? Not at all 1-3 times per week 4-6 days a week Everyday I have someone else drive for me Question Title * 5. Approximately how many miles do you drive each week on average? 1-10 Miles 11-30 Miles 31-75 Miles 76-100 Miles More than 100 Miles Question Title * 6. Are you able to pump your own gas at service stations or do you require assistance? Can pump my own Require assistance Can pump my own but prefer having assistance Question Title * 7. In your opinion, is the Department of Justice doing enough to enforce the refueling policy? Yes No Question Title * 8. What is your primary reason for driving? Getting to/from work Errands/personal reasons Medical appointments Travel/leisure Other (please specify) Question Title * 9. Are you aware of the refueling assistance policy set forth by the US Department of Justice? Yes No Next