District 11 Public Involvement Comment Form

Feedback
Required fields are marked with an asterisk.(*)

Please select the project you would like to provide feedback for

How did you hear about this public meeting?

In what municipality do you live?

In what municipality do you work?

What interest do you represent?

If Other, Please Explain

What concerns do you have about the project?

What would you like the project team to consider as part of this project?

Additional Comments

In the future, do you prefer our public meetings to be held virtually or in person?

If virtual is your preference, do you have any suggestions to improve the format or the manner in which information is presented?

Contact Information (Optional)

Would you like a PennDOT representative to contact you regarding your answers?

NoYes

First Name

Last Name

Phone Number (XXX-XXX-XXXX)

Email Address

Voluntary Information Survey (Optional)

As a recipient of federal funds, PennDOT strives to involve all groups relevant to its projects in its public involvement activities. The following information will assist PennDOT in planning outreach to communities during the course of the project. Thank you for your participation.

Zip Code

County

Gender

Race/Ethnicity

Disability

NoYes

Household Income

First Language

Second Language

Generate a new image Play the audio code

Enter the code from the image