* 1. Where do you live?

* 2. What is your age?

* 3. What is your employment status?

* 4. Do you have a disability?

* 5. Do you use a wheelchair?

* 6. What is your main form of transportation? (Choose one)

* 7. On average, what percentage of trips do you make using the following modes of transportation?

* 8. If you have school-age children in your household, what forms of transportation do they use?  Mark all that apply.

* 9. What are your typical destinations, and how often do you travel there on an average week/month?

  1-2 times/month 1-2 times/week 3-5 times/week 6-7 times/week
In-County Medical Appointments
Out-of-County Medical Appointments
Senior/Community Center
Recreation/Social Gathering

* 10. If you had $100 to spend on transportation, how would you divide it among the following types of projects?

* 11. What is the estimated one-way distance for a typical travel trip to work, school, or other appointment?

* 12. On an average month, how often do you travel out of the County and for what reasons?  Choose only those that apply.

  1 time 2-3 times 4-5 times 6 or more times
Medical Appointments
Recreation/Social Gathering

* 13. Please indicate your degree of concern over the following transportation related issues:

  Very Concerned Somewhat Concerned Not Concerned
Not enough bike paths/lanes
Condition of local streets/roads
Condition of State highways
Traffic Congestion
Unsafe streets, roads, or highways
A need for new streets, roads, or highways
Not enough local bus services
Not enough/inadequate sidewalks

* 14. Please explain any other issues or concerns you feel should be included with regards to future transportation planning in the space below.