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* 1. Who is completing this survey?

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* 2. In which county do you reside?

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* 3. Over the last 6 months did you miss your appointment with the provider because you did not have access to transportation?

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* 4. Over the last 6 months, how much did you rely on others for transportation?

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* 5. If you depend on others for your trips, who do you depend on?

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* 6. Which of the following statements about your local public transportation system are true for you? (Check all that apply)

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* 7. During the past 6 months, which of the following factors prevented you from taking trips outside your home? (check all that apply)

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* 8. What is your age?

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* 9. What is the primary language spoken in your household?

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* 10. What is your race?

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