Medicaid Transportation User Survey

Age:

Gender:

Male

Female

Race (Optional):

Do you live in:

Rural area

Urban area

On the average, how many times per month do you use Medicaid transportation?

Do you experience lengthy delays when calling to schedule a ride?

Do you encounter scheduling difficulties?

Yes

No

If Yes please explain:

Do you have a primary location you are transported to regularly?

Yes

No

If you answered Yes please specify:

Do you use Medicaid transportation to get to:

Is your driver on time picking you up from your home?

Is your driver on time picking you up to take you home?

Overall, how do you rate the friendliness and courtesy of the drivers?

Do drivers assist with getting in and out of the vehicle, if needed?

Do drivers drive in a safe manner?

Yes

No

If you answered no, please explain:

Are seatbelts and/or child safety seats available on the vehicles?

Yes

No

Are the vehicles equipped to handle any special needs that you may have?

Yes

No

If you answered no please expain:

Overall, are you satisfied with the Medicaid transportation service?

Yes

No

Have you ever filed a complaint with the transportation provider/broker?

Yes

No

Suggestions for improvement of the transportation service: