SURVEY

TRANSPORTATION SURVEY

Was it too difficult to go to the doctor because of trouble getting a ride?	Yes No Sometimes
Does the inability to have dependable transportation affect your health problems?	Yes No Sometimes
Does your income play a part in your ability to find transportation?	Yes No Sometimes
Does where you live make it difficult to find transportation?	Yes No Sometimes
Do you have a disability that limits the type of transportation you can utilize?	Yes No
If so, what type of transport is needed?	Wheelchair Ambulance Other
Do you have adults living in your home other than yourself?	Yes No
Is there a vehicle located at your residence?	Yes No

What kind of transportation do you use when going to the following places?
DOCTOR
GROCERY STORE
PHARMACY
PAYING BILLS
SOCIAL EVENTS
What type of health problems do you have?
Which of the following benefits do you receive? (check all that apply):	Mediciad Medicare Social Security SSI Black LungVeterans BenefitsPrivate PensionPrivate Health Insurance
What is your race?	White Black Other
What is your sex?	Male Female
How old are you?	0-10 11-25 26-40 41-55 56 and older
What county do you live in?
Comments?:

E-mail address