* 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. If transportation was easy to use and available to you and/or your family, which of the following would cause you to use the service? (please select all that apply)

* 3. What changes could be made to your local transportation options to make using them a more appealing to you? (select all that apply)

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

* 5. When do you need transportation most often for each of the following general purposes? (select all that apply)

  Medical/Health Care Nutrition Employment Shopping Recreation/Social Other
12 A.M - 6 A.M.
6 A.M - 8 A.M.
8 A.M. - 12 P.M.
12 P.M. - 3 P.M
3 P.M - 6 P.M.
6 P.M. - 9 P.M.
9 P.M. - 12 A.M.

* 6. What City/Town, County or Counties are the locations from QUESTION 5 located in?

* 7. Do you or a family member need transportation outside of your County but sometimes or never have it?

* 8. How old are you?

* 9. Is English your first language?

* 10. What city/town do you live in (or what is the nearest city or town to your home)?

* 11. What county do you live in?

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

* 13. If you work outside of your home, who is your employer(s)?

* 14. What City/Town or County is your employer(s) located?

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

* 16. Are you or a family member currently using any transportation services that are available to you through the Medicaid program?

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