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? If yes, skip to question 12.

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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. If using public transportation, how do you typically pay?

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* 9. What is your age range?

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* 10. Are you a veteran?

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* 11. Are you disabled?

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* 12. Would you be interested in attending a Community Education Forum for transportation options? If so, what town/city?

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* 13. Contact Information

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