SURVEY FORM

WAWANCARA DI TEPI JALAN

(ROADSIDE INTERVIEW SURVEY)

Location Code ………………………………… Surveyor name ………………………………………………………………………. Supervisor name …………………………

Direction From: ………………………………… Day 1. Minggu 2. Senin 3. Selasa
To: ………………………………… 4. Rabu 5. Kamis 6. Jumat 7. Sabtu
Month/Date ………………………………… Shift 1. 06.00 - 14.00 2. 14.00 - 22.00 3. 22.00 - 06.00

Sample No.
………………………………………… ………………………………………… …………………………………………
Interview Time
Vehicle Type

1. Motorcycle 3. Angkot/Small Bus 5. Medium Bus 7. Truck 2-axle/4W 9. Truck 3-axle 11. Truck Trailler/semi
2. Private Car 4. Pick-up / Box 6. Large Bus 8. Truck 2-axle/6W 10. Articulated Truck

No. of Person ………..…...person ………..…...person ………..…...person

No. of Female in
Vehicle ………..…...person ………..…...person ………..…...person

Female Driver 0. Tidak / 1. Ya Ya / Tidak Ya / Tidak

No. of Disable
(Female) * ………..…...person ………..…...person ………..…...person
No. of Disable
(Male) * ………..…...person ………..…...person ………..…...person
Main Commodity

………………………………………… ………………………………………… …………………………………………

Volume (%)
………………………………………… % ………………………………………… % ………………………………………… %
Vehicle Capacity
(Kg) ………………………………………… ………………………………………… …………………………………………
Freight License Plate Vehicle Freight License Plate Vehicle Freight License Plate Vehicle

Photograph

Provinsi Provinsi Provinsi

Origin
…………………………………….. …………………………………….. ……………………………………..
Kabupaten/Kodya Kabupaten/Kodya Kabupaten/Kodya

…………………………………….. …………………………………….. ……………………………………..

Kecamatan Kecamatan Kecamatan

…………………………………….. …………………………………….. ……………………………………..

Kelurahan/Desa/Landmark Kelurahan/Desa/Landmark Kelurahan/Desa/Landmark

…………………………………….. …………………………………….. ……………………………………..

Departure Time
Type of Origin 1. Home 2. Work Place / Office 1. Home 2. Work Place / Office 1. Home 2. Work Place / Office
3. Study Place 4. Recreation Place 3. Study Place 4. Recreation Place 3. Study Place 4. Recreation Place
5. Shopping Place 6. Personal/Private Business 5. Shopping Place 6. Personal/Private Business 5. Shopping Place 6. Personal/Private Business
7. Others ( ) 7. Others ( ) 7. Others ( )

Provinsi Provinsi Provinsi

Destination
…………………………………….. …………………………………….. ……………………………………..
Kabupaten/Kodya Kabupaten/Kodya Kabupaten/Kodya

…………………………………….. …………………………………….. ……………………………………..

Kecamatan Kecamatan Kecamatan

…………………………………….. …………………………………….. ……………………………………..

Kelurahan/Desa/Landmark Kelurahan/Desa/Landmark Kelurahan/Desa/Landmark

…………………………………….. …………………………………….. ……………………………………..

Estimated Time
Arrived
Type of Destination1. Home 2. Work Place / Office 1. Home 2. Work Place / Office 1. Home 2. Work Place / Office
3. Study Place 4. Recreation Place 3. Study Place 4. Recreation Place 3. Study Place 4. Recreation Place
5. Shopping Place 6. Personal/Private Business 5. Shopping Place 6. Personal/Private Business 5. Shopping Place 6. Personal/Private Business
7. Others ( ) 7. Others ( ) 7. Others ( )

Ket: * Khusus kendaraan Pribadi