Thank you for your interest in speaking with us!
We are speaking with people who live in or near Flagstaff about their transportation needs and the effects of the recent wildfires.  Please complete these screening questions.

If you are selected to participate, a researcher will speak with you for about 60 minutes by Zoom or phone, and we will give you a $25 Visa gift card as a thank-you.  If you have questions, please email talktous@social-motion.org

Sign in to Google to save your progress. Learn more
What is your preferred name?
What is your email address?
What is your phone number?
What is the best way to reach you?
Clear selection
What is your age? *
What is your race? Select all that apply. *
Required
Have you been affected by the recent wildfires in any of the following ways?
*
Yes
No
Do you drive?
Do you have a car?
Do you own your home?
Do you have a disability or medical condition that makes it difficult to get around?
Do you have a respiratory condition such as Asthma or COPD?
What is your gender identity? (Select all that apply)
Do you have access to a device where you could receive a Zoom call?
Clear selection
What time(s) are usually good for you to have a conversation? If we select you, we will contact you to set up a precise appointment.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms