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)

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* 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)

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)

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* 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)

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

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

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)

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* 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)

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

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

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

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

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

How old are you?

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* 8. How old are you?

Is English your first language?

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* 9. Is English your first language?

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

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

What county do you live in?

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* 11. What county do you live in?

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

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

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

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

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

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

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

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

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

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* 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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