Pre-Survey Aging Driver Resource Guide

Question Title

* 1. In which jurisdiction do you live?

Baltimore City

Allegany

Anne Arundel

Baltimore County

Calvert

Caroline

Carroll

Cecil

Charles

Dorchester

Frederick

Garrett

Harford

Howard

Kent

Montgomery

Prince George's

Queen Anne's

St. Mary's

Somerset

Talbot

Washington

Wicomico

Worcester

Question Title

* 2. Identify your age group

Younger than Age 50

Ages 50 - 59

Ages 60 - 69

Ages 70 - 79

Ages 80 - 89

Age 90 and Older

Question Title

* 3. What’s the average number of days per week that you drive?

Hardly Ever

Avg 1 - 2 Days / Week

Avg 3 - 5 Days / Week

Avg 6 - 7 Days / Week

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* 4. Which of the following topics are of most interest to you?

How health and age can impact driving

What the MVA's medical review process is and what to expect

How to talk with family, friend, or clinician about driving

How to sharpen driving skills and knowledge

Transportation options if one has to stop driving

How to know if I am a safe driver

How to transition from driving

When and where to get a driving assessment or evaluation

Other (please specify)

Question Title

* 5. What do you plan to do with the Resource Guide?

Keep it for reference

Use it to address an issue I am experiencing

Use it to talk to someone about MY driving options

Use it to talk to someone about THEIR driving options

Give it to a friend

Give it to a patient / client

Give it to a family member

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* 6. How important is it for you to have this Resource Guide in print – rather than online?

Very Important

Somewhat Important

No opinion

Not Really Important

Not Important at All

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* 7. Please provide your phone number or email to contact you in a few months for a brief follow-up survey. Your private contact information will only be used for this specific purpose and won’t be shared with others.

Name

Phone Number

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* 8. Online, or if paper survey, what organization and/or event survey was completed?

Question Title

* 9. Date survey completed

Date / Time

Date