Trumbull County Provider Survey

I. ORGANIZATION CHARACTERISTICS AND SERVICES PROVIDED

The first set of questions will provide us with the general characteristics of your organization and the nature of the services provided.

Trumbull County is updating its Coordinated Public Transit-Human Services Transportation Plan, which seeks to develop strategies to address unmet transportation needs in the County. Please help us determine what the transportation needs are in Trumbull County by completing this survey.

If you have any questions regarding this survey, please contact Julie Schafer via email at jschafer@rlsandassoc.com or via telephone at (937)299-5007. You may also complete the survey online at https://www.surveymonkey.com/r/TrumbullProvider

Question Title

* 1. Identification of Organization

Respondent's Name:

Title:

Organization:

Street Address:

City

State

Zipcode

Work Phone:

Fax:

Respondent's E-mail:

Respondent's Website Address:

Question Title

* 2. What are the major functions/services of your organization? (Select all of the following options that apply)

a. Transportation

b. Health Care

c. Social Services

d. Nutrition

e. Counseling

f. Day Treatment

g. Job Training

h. Employment

i. Rehabilitation Services

j. Diagnosis/Evaluation

k. Job Placement

l. Residential Facilities

m. Income Assistance

n. Screening

o. Information/Referral

p. Recreational/Social

q.Home Health Care

r. Housing

Other (please specify)

Question Title

* 3. Under what legal authority does your organization operate?

a. State government department

b .Private nonprofit organization

c. Private, for-profit

Other (please specify)

Question Title

* 4. What is the geographic area that your serve?

a. Anywhere within Trumbull County (yes or no)

b. Multiple Counties (please list):

c. Within city or town limits (please list):