District 5 Public Involvement Comment Form

Required fields are marked with an asterisk.(*)

Feedback

Please select the project you are interested in providing feedback for.

In what municipality do you live?

In what municipality do you work?

What is your interest in the project? Please select all that apply.

Are you representing an organization, business, or municipality? If so, please list the name.

Do you favor the proposed improvements?

What questions or concerns do you have about the project? (Note: You must provide contact information in the section below if you'd like answers to any questions.)

Are the plans informative?

What could be done to improve the presentation of these plans?

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

Additional Comments

Contact Information (Optional)
Please note a public comment may be considered a public record subject to the Pennsylvania’s Right-to-Know Law, 65 P.S. § 67.101 et seq.

First Name

Last Name

Phone Number

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

Disability? Yes / No / Prefer not to say

Pennsylvania Code (16 Pa. Code § 44.4) defines a handicapped or disabled person as a person who has or is one of the following:
(A) A physical or mental impairment which substantially limits one or more major life activities.
(B) A record of an impairment.
(C) Regarded as having an impairment.

Race/Ethnicity (Please select all that apply)

Household Income

Please answer the following two questions only if you speak a language other than English at home.

Language spoken at home:

For example: Korean, Italian, Spanish, Vietnamese

How well do you speak English

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