Employee Transportation Survey

Please complete the following form.

If you have questions about this survey or you are not an employee of College Hospital Cerritos please email Marites Leija at collegehr@chc.la or call (562) 924‑9581x3595 for assistance.

Step 1: Name

First Name:

Last Name:

Middle Initial:

Employee ID:

Step 2: Home Address - Address is confidential and will not appear on anyone else's RideGuide. *

Street Number:

Street Name:

City:

State:

Zip Code:

Home Cross Streets:

and

Step 3: Contact Information

Area Code, Phone Number and ext:

This phone is my:

Home Phone Number

Work Phone Number

Cell Phone Number

Email Address:

Step 4: Work Hours and Commute Information

Work Department:

How do you typically get to work?

What is the one-way distance in miles from your home to your workplace?
All employees must complete this field. Please provide one-way distance in whole numbers. Do not use decimals.

Typical Work Hours:

Start Time:

End Time:

If your work hours vary from day to day please check here.

If you have up to one hour flexibility in your start and leave times, please check here.

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.

In the blue section below, the most common misinterpreted codes are defined.

Commute Modes Explained

A.	Zero Emission Vehicle (Electric Vehicle/Fuel Cell)

Select this mode for every day that you commute to work in a zero emission vehicle. If you drive alone or carpool in a zero emission vehicle, please select Zero Emission Vehicle on that/those day(s). Zero Emission Vehicle can also include Hydrogen Fuel Cell vehicle. Employees arriving to work in a Plug-In Hybrid Electric Vehicle (PHEV) meet the definition of a zero emission vehicle provided that the entire trip to work is made exclusively under electric power. This applies to plug-in vehicles with all electric range that can travel exclusively under electric power without use of the gasoline engine or cogeneration system.


F.	Telecommute (Work from home/Remote)

Select this mode on the day(s) you telecommute. Telecommuting is defined as working at home, off site, a satellite office or at a telecommuting center during the entire day. Select this mode if you work at home, or if your commute to a telecommuting center results in a reduction of 51% or more of your commute distance between your home and your worksite. Remote employees are employees who are assigned to a regulated worksite, but primarily live and work outside of the South Coast AQMD and physically commute to the regulated worksite less than five days a year.


G.	Noncommuting (at site for 24 hours or outside district for 24 hours)

Select this mode to indicate the days you are either outside the South Coast AQMD jurisdiction (all of Orange County and the non-desert portions of Los Angeles, San Bernardino, and Riverside counties) to complete work assignments, or you generate no vehicle trips associated with arriving at the worksite (e.g., hospital employees, fire fighters, airline employees who stay at the worksite over a 24 hour period, etc.)


Compressed Work Week Day(s) Off:

Select one of these modes to indicate your compressed work weekday off. Select this only if you were off during the survey week. Compressed work week includes rotating day off (RDO), flex day off, and other alternate work week schedules.

Code X: 3/36- work 3 days/12 hours each day; 2 days off

Code Y: 4/40- work 4 days/10 hours each day; 1 day off

Code Z: 9/80- work 9 days/80 hours; 1 day off in a 2-week period

If you have more than 2 days off in a 7-day period due to a compressed work week or alternative work schedule (i.e., rotating day off (RDO), flex day off, or 4/40, 9/80 or 3/36 schedule), please review options X, Y, and Z above to note your days off.

Monday 8/31/2026

Monday Commute Mode

Monday Time You Began Work

Tuesday 9/1/2026

Tuesday Commute Mode

Tuesday Time You Began Work

Wednesday 9/2/2026

Wednesday Commute Mode

Wednesday Time You Began Work

Thursday 9/3/2026

Thursday Commute Mode

Thursday Time You Began Work

Friday 9/4/2026

Friday Commute Mode

Friday Time You Began Work

Saturday 9/5/2026

Saturday Commute Mode

Saturday Time You Began Work

Sunday 9/6/2026

Sunday Commute Mode

Sunday Time You Began Work

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. *

*Per California Penal Code section 637.6 this information will be used for carpooling or ridesharing purposes. I understand that my signature allows the information provided to be used for ridesharing purposes in the regional ridematching database sponsored by Los Angeles County Metropolitan Transportation Authority (Metro), Orange County Transportation Authority (OCTA), Riverside County Transportation Commission (RCTC), San Bernardino County Transportation Authority (SBCTA), and Ventura County Transportation Commission (VCTC) and through joint partnerships with local cities and Transportation Management Associations to promote ridesharing programs and reduce congestion. I understand these entities are strictly prohibited from disclosing this information to any other third parties.

I acknowledge that my participation in ridematching is voluntary and that I am responsible for my participation in a rideshare arrangement. I understand that the sponsoring agencies shall have no responsibility or liability for any claims, expenses or damages resulting from any individual's participation.