1. What era of conflict did you serve?(select all that apply)

2. Did you serve during war or Peace? War Peace Both

3. Please select your age bracket 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99+

4. Which of these services do you currently use in public transportation?
(select all that apply)

How satisfied are you with the transportation service that you receive on a scale from 1-4, 1 meaning less satisfied and 4 meaning more satisfied.
1 2 3 4

5. Which of these home based services do you currently use? (select all that apply)

6. Which of these social services do you use? (select all that apply)

7. What is your education level? Some High School High School Diploma G.E.D. Vocational Some College Associate Degree B.A. or B.S. Degree M.A. Degree Ph.D. Degree

8. What is your annual household income? 0 - 14,000 15, 000 - 19,000 20,000 - 29,000 30,000 - 39,000 40,000 - 49,000 50,000 - 59,000 60,000 - 69,000 70,000 - 79,000 80,000 - 89,000 90,000 - 99,000 100,000 - 109,000 110,000 - 119,000 120,000 +

9. What is your race?  American Indian or Alaska Native African American / Black Asian Caucasian / White Hispanic or Latino (Caucasian race only) Hispanic or Latino (all other races) Native Hawaiian or other Pacific Islander Other

10. What is your current occupation?

11. What is your marital status?

Married Divorced Widowed Single

12. Do you have any children living at home?

No Yes If Yes, how many? 1 2 3 4 5 6 7 8 9 10 11 12 +
If children are present in the home what are there ages?

13. What social outlets do you use? (select all that apply)

Church
Sports, spectator     Please list
Sports, participant   Please list
Hunting
Fishing
Other

14. Are you Male Female

15. What services do you need to increase your quality of life?

16. What services does your caregiver need to increase your quality of life?

17. Are you a disabled veteran? Yes No

18. If yes, what is your disability rating? 0-10% 10-20% 23-30% 30-40% 40-50% 50-60% 60-70% 70-80% 80-90% 90-100%

19. Are you a member of any veterans group? (choose all that apply)

D.A.V. V.F.W. Purple Hearts American Legion Other

20. What is your county of residence? Anderson Bedford Benton Bledsoe Blount Bradley Cambell Cannon Carroll Carter Cheatham Chester Claiborne Clay Cocke Coffee Crockett Cumberland Davidson Decatur DeKalb Dickson Dyer Fayette Fentress Franklin Gibson Giles Grainger Greene Grundy Hamblen Hamilton Hancock Hardeman Hardin Hawkins Haywood Henderson Henry Hickman Houston Humphreys Jackson Jefferson Johnson Knox Lake Lauderdale Lawrence Lewis Lincoln Loudon Macon Madison Marion Marshall Maury McMinn McNairy Meigs Monroe Montgomery Moore Morgan Obion Overton Perry Pickett Polk Putnam Rhea Roane Robertson Rutherford Scott Sequatchie Sevier Shelby Smith Stewart Sullivan Sumner Tipton Trousdale Unicoi Union Van Buren Warren Washington Wayne Weakley White Williamson Wilson

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