Please complete and submit by July 10, 2017

* 1. Mark ALL of the transportation you or your family have used during the past 12 months to travel to work/appointments/shopping/social activities/etc:  (check all that apply)

* 2. What changes could be made to your local transportation options to make using them more useful to you?  (check all that apply)

* 3. Which of the following are your most commonly visited destinations or places you most often need to visit when transportation is available to you?  (check all that apply)

* 4. Do you or a family member need transportation outside of the county in which you live, but sometimes or never have it?

* 5. How old are you?

* 6. I am . . .

* 7. Is English your first language?

* 8. In what city/town do you live (or city/town nearest your home)?

* 9. In what county do you live?

* 10. How many children under the age of 18 live in your household?

* 11. Including you, how many people live in your home?

* 12. Do you have a valid driver’s license?

* 13. How many licensed drivers live with you?

* 14. Do you have a car?

* 15. How many vehicles are available in your household?

* 16. Which of the following BEST applies to you?  Are you presently:

* 17. If you work outside your home, who is your employer?

* 18. What is the city/town or county in which your employer is located?

* 19. Do you have a disability which requires you to use a cane, walker, wheelchair, and/or another device to help you get around?

* 20. Are you on Medicaid?

* 21. Do you use Medicaid transportation services?

* 22. Do you need wheelchair accessible transportation services?

* 23. Personally, when do you need transportation most often for each of the following general purposes?  (check all that apply)

  Medical/Health Care Nutrition Employment Shopping Recreational/Social Religious
12 am - 6 am
6 am - 8 am
8 am - 12 pm
12 pm - 3 pm
3 pm - 6 pm
6 pm - 9 pm
9 pm - 12 am

* 24. In the last month, how often have you...

  Never (0 times) Sometimes (1-2 times) Frequently (3-4 times) Almost Always (5+ times)
Missed a medical appointment IN your community because you did not have a ride?
Missed a medical appointment OUTSIDE your community because you did not have a ride?
Have you been unable to shop for GROCERIES because you did not have a ride?
Have you been unable to get together with FAMILY because you did not have a ride?
Have you been unable to attend SOCIAL FUNCTIONS because you did not have a ride?
Have you been unable to go to a RELIGIOUS activity because you did not have a ride?

* 25. Please provide your name and address

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