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* 1. What community do you live in? (select one)

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* 2. Should local municipalities provide a transportation program for their senior and disabled residents?

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* 3. Are you a senior (aged 55 or over) or a disabled adult (aged 18 or older)?

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* 4. How often do you use your community transportation program? (check one)

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* 5. How many people in your household use your community's transportation program?

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* 6. As a senior or disabled adult, which modes of transportation do you use? 

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* 7. If your municipality provided a transportation program/service for a nominal fee to take you to medical appointments, work, grocery shopping, hair salons, civic events, lunch with friends, the library, etc., and was available Monday through Friday, how often do you estimate you would use it?

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* 8. Do you know someone age 55 or older or someone disabled age 18 or older who would use the transportation program/services?

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* 9. OPTIONAL - If you provide your name and contact information we can make sure you are notified of any updates regarding your community transportation program and availability. 

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* 10. Please provide any comments.

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