MobilityWorks appreciates you taking the time to complete this survey. We will make a $5.00 donation to UCP/CLASS for every survey that is fully completed. We will also randomly select one name from all of the surveys completed, and that person will receive a $250 American Express gift card! Surveys must be completed by midnight December 31st. We do value your privacy. MobilityWorks WILL NOT share your information with any other agency or business for marketing purposes, or any other use.

* 1. Contact Information ( * are required answers)

* 2. How old are you?

* 3. Are you a veteran?

* 4. What mobility device are you currently using?

* 5. Do you visit a support group for your disability?

* 6. What type of transportation do you use?