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* 1. Please provide information about you and your organization.

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* 2. Please select your agency type.

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* 3. Of the clients you have contact with most often through your agency, what is the primary purpose of that contact? Select only one.

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* 4. In what County is your organization located? Select only one.

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* 5. What Counties comprise your service area? Check all that apply.

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* 6. How many clients does your organization assist annually?

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* 7. Please indicate the kind of transportation assistance your agency offers and estimate the number of clients served in each category.

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* 8. Please indicate the hours in which your agency provides services.

  Monday Tuesday Wednesday Thursday Friday Saturday Sunday
12 A.M - 6 A.M.
6 A.M - 8 A.M.
8 A.M. - 12 P.M.
12 P.M. - 3 P.M.
3 P.M - 6 P.M.
6 P.M. - 9 P.M.
9 P.M. - 12 A.M.

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* 9. Which best describes your advance reservation-for-transportation service? (Please check all that apply)

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* 10. On a weekly basis, about how many appointments are canceled?

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* 11. Do you document cancellations?

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* 12. Do your clients routinely have transportation needs that you cannot serve?

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* 13. Please rank the significance of the transportation issues listed below as they relate to access to jobs. (1 is the most significant issue, 2 is 2nd most significant issue, etc.)

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* 14. Please rank the significance of the transportation issues listed below as they relate to access for people with disabilities. (1 is the most significant issue, 2 is 2nd most significant issue, etc.)

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* 15. Which of the following would be the best way to inform residents about your services? Check all that apply.

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* 16. Do the majority of your clients have reliable access to the internet?

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* 17. From what one general (or specific) area do the majority of your clients travel? Examples: town, county, neighborhood, etc.

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* 18. To what general (or specific) area do the majority of your clients travel? Examples: town, county, neighborhood, etc.

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* 19. To what extent does your agency coordinate any transportation services with other agencies in your area (e.g., share riders, joint training, pool insurance, etc.)? Please list the coordinating agencies.

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* 20. What other transportation issues or gaps, if any, are you aware of that were not covered in the previous questions? Please be specific in describing transportation needs in your service area that are not being adequately met, along with recommended solutions.

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