Funded by Buhl Regional Health Foundation
Collaborative Partnership between PHN Charitable Foundation and Mercer County Regional Council of Governments

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* 1. Do you currently have transportation?

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* 2. What type of transportation do you currently use: (Check all that apply)

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* 3. What city do you reside in?

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* 4. What days of the week do you use or need transportation? (Check all that apply)

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* 5. During what time(s) of the day is it most difficult for you to get transportation? (Check all that apply)

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* 6. Where do you need transportation to? (Check all that apply)

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* 7. In a typical month, where do you need to go that requires transportation? (Please check all that apply):

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* 8. Have you had to cancel or reschedule doctor appointments due to lack of transportation?

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* 9. If admitted to the hospital, have you had difficulties getting home after discharge?

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* 10. What is your age range?

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* 11. Are you a veteran?

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* 12. Are you disabled?

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* 13. Contact Information

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