The purpose of this survey is to gather information from residents of WAYNE COUNTY to help determine if transportation issues impact WAYNE COUNTY residents’ health by impacting their ability to make and keep health related appointments.  The information provided will be used to develop recommendations for improving access to health care in the community. If you have any questions please contact: Leslie Baus, Wayne County Mobility Coordinator at Community Action Wayne/Medina, 330-264-8677 or at lbaus@cawm.org.

* 1. Name (optional)

* 2. Telephone Number (optional)

* 3. E-mail Address (optional)

* 4. I am...

* 5. I live in...

* 6. What is the total number of people in your household?

* 7. Approximately how many health related appointments do you or a family member have in a year?

* 8. How do you get to your health care related appointments?  (Mark all that apply)

* 9. Do you have trouble making an appointment or keeping an appointment because of transportation issues?

* 10. If you are having transportation issues, what issues are you facing? (Mark all that apply.)

* 11. How many times in 2016 did you miss a health care related appointment because you didn't have transportation?

* 12. How many times in 2016 did your child or children miss a health care related appointment because of not having transportation?

* 13. Do you feel like not making an appointment or missing an appointment has had a negative health impact on you or a family member?

* 14. Do you feel like there is anything that health care providers can do to help with your transportation issues to health care related appointments?

* 15. Do you feel that you know what resources are available to you if you need help with transportation to health care related appointment? Resources could include many things like public transit, social service agencies or even family members?

* 16. Do you have any other comments or thoughts to share regarding transportation and health related appointments for residents in WAYNE COUNTY?

* 17. If you have any stories that you would like to share about this issue please include here or you can call: Leslie Baus, Wayne County Mobility Coordinator at Community Action Wayne/Medina, 330-264-8677 or at lbaus@cawm.org.

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