Fillable ADA Para Application Rev8 2017

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ADA Para Application Rev8 2017

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Revised October 2017
_______
_____________________________________________________
Accessible Services
1221 R Street
S
acramento, CA 95811
PHONE: 916-557-4685 or 916-557-4686 (TDD)
FAX: 916-455-3924
paratransit@sacrt.com
www.sacrt.com/accessibleservices.stm
Thank you for inquiring about eligibility for ADA Paratransit Service. Sacramento
Regional Transit’s Paratransit Service is a “Safety Net” for people with physical, cognitive
or visual disabilities that are functionally unable to independently use the RT fixed route
service either all of the time, temporarily or only under certain circumstances. Enclosed
are the ADA Paratransit Application and Eligibility Brochure that explains ADA Paratransit
Service. Please read the Eligibility Brochure carefully before completing your application.
The Steps in the Eligibility Process
1. Request the application packet.
2. Read the Eligibility Brochure that is enclosed.
3. Complete all questions on the Paratransit Application that follows this page.
4. Submit your application to your physician, or other professional, to complete the
professional verification section.
5. Mail your signed and completed application and professional verification form to:
Sacramento Regional Transit District, Accessible Services
PO Box 2110
Sacramento, CA 95812-2110
6. You may be asked to attend an in-person interview. Your eligibility will be
determined within 21 days from the date you complete your telephone and/or in-
person interview and functional assessment. You will be notified by letter as to your
eligibility status.
7. If you do not receive written notice of RT’s decision within 21 days, you may
request paratransit services until a decision has been made by calling
(916) 557-4685 or (916) 557-4686 (TDD).
An incomplete application will be returned and will delay processing.
EVERY QUESTION MUST BE ANSWERED AND LEGIBLE.
Reset Form
Revised October 2017
-
1
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Application for ADA Paratransit Eligibility
Please complete ALL sections of this form. An incomplete application will be returned.
The information you provide will help determine what type of transportation service is the
right service for you. All information will remain confidential.
APPLICANT INFORMATION (PLEASE PRINT)
First Name___________________________________________ Middle Initial_______
Last Name______________________________________________________________
Mailing Address_____________________________________________ Apt#_______
City_____________________ State_______ Zip__________ County_____________
Home Address __________________________________________________________
(if different from mailing address)
Name of Facility/Apartment Building___________________________Gate Code:______
(if applicable) (if applicable)
City_____________________ State_______ Zip__________ County_____________
Phone (daytime) ______________________ (evening) _______________________
Cellular #______________________ TTY for hearing impaired___________________
(if applicable)
Email address (if available)____________________________________________________
Date of Birth _____/_____/_____ SSN___________ Sex: Male
Female
Mo
nth Day Year Last 4 Digits (only)
New Application or
Recertification (ID# ________________)
Please send me written information in an alternate format.
Large Print
Audio Tape
Braille
CD
Other:_____________
Español
中文
Русский
tiêng Việt
Hmoob
Please provide the name of a LOCAL relative/friend in case of an emergency:
Name_________________________________ Relationship____________________
Phone (daytime) ________________________ (evening) _____________________
FOR STAFF USE ONLY
Date Received __________________________________ Initials _________
Date Returned __________________________________ Initials _________
Application Date Complete/Distributed ___________________________ Initals _________
Revised October 2017
-
2
-
How do you travel now? Please check all that apply to you.
walk
drive a car
ride in someone’s car
taxi
bicycle
paratransit
RT bus
RT light rail train
Other:___________________
List your common trips and the places you most often travel to in the spaces
indicated below. Please refer to the following as an example
:
Trip destination:
Building Location / Name
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9
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6
6
Number and Street City ZIP Code
A. Trip destination:
Building Location / Name ________________________________________________
________________________________________________________________________________
Number and Street City ZIP Code
B. Trip destination:
Building Lo
cation / Name ________________________________________________
________________________________________________________________________________
Number and Street City ZIP Code
C. Trip destination:
Building Location / Name ________________________________________________
________________________________________________________________________________
Number and Street City ZIP Code
Revised October 2017
-
3
-
Do you have a cognitive or physical disability that, some or all of the time, causes
you to be unable to get on, ride or get off the fixed-route buses or light rail trains
by yourself, without the help of another person?
Yes (If yes, explain)
No:
What types of disabilities cause you to be unable to use RT’s buses or trains?
physical disability
visual impairment/blindness
developmental disability
mental illness
recent surgery
other________________
When was your disability diagnosed? __________________
Month/Year
Is your disability considered Stable?
Yes
No
Is your disability considered Progressive?
Yes
No
Is your disability temporary?
Yes, I expect it to last _______months.
No, it is permanent
I don’t know.
Paratransit Operators are unable to perform the duties of a Personal Care
Attendant (PCA). Will you need to travel with a PCA or someone to assist you
when you use paratransit?
Yes; sometimes
Yes; always
No
If always or sometimes, how does a PCA or other person assist you?
Can you wait for a regular RT bus or light rail train?
Yes
Only if there is a bench or shelter
No more than 15 minutes
No
Can you maintain balance while seated on a moving vehicle?
Yes
No
How far can you walk on level ground?
Less than 1 block
1 blo
ck
2 blocks
3 or more blocks
How far can you go on level ground with your mobility aid, if you use any?
Less than 1 block
1 block
2 blocks
3 or more blocks
Revised October 2017
-
4
-
MOBILITY AID AND/OR EQUIPMENT INFORMATION
If you use a power wheelchair, or scooter, RT will need to verify what you and your
wheelchair weigh together. Many power wheelchairs and scooters are very heavy.
(RT paratransit vehicle lifts are designed to lift 600 to 800 pounds, depending on
the paratransit vehicle type.)
Which of these mobility aids do you currently use when traveling? Please check all
that apply to you. Do not select a device that you are waiting on for approval or
prescription.
white cane
powered wheelchair *
walker
support cane
powered scooter/cart *
walker with seat
crutches
manual wheelchair *
portable oxygen
leg brace
power assist wheelchair
prosthesis
service animal
communication board
no mobility aid
other (please specify)__________________________________
* “Wheelchair” means a three or more wheeled mobility device.
If you checked manual wheelchair, power wheelchair, or powered scooter/cart,
please provide the following information:
Is your mobility device oversized?
Yes
No
Does your mobility device weigh more than 600 pounds when occupied?
Yes
No
Do you know how much you and your wheelchair weigh together?
Yes
No
If yes, please provide the total weight: __________________lbs.
What is the make/model of your wheelchair or scooter?
Make ______________________ Model __________________________________
What is the width of your wheelchair or scooter? ___________inches (if available)
What is the length of your wheelchair or scooter? __________inches (if available)
Revised October 2017
-
5
-
CURRENT USE OF RT'S FIXED-ROUTE BUSES AND LIGHT RAIL TRAINS
Do you use RT's fixed-route buses and/or light rail trains by yourself?
Yes
No
If yes, how often?________________ Which routes do you use?_________________
When was the last time you used RT's fixed-route by yourself?_______________
Do you n
eed someone to travel with you when you travel in the community or
when you use the accessible fixed-route buses or light rail trains?
Yes; sometimes
Yes; always
No
Have you ever had training on how to travel around the community or how to use
RT’s accessible fixed-route buses or light rail trains?
Yes
No
Never ridden bus/light rail
FUNCTIONAL ABILITIES: USING FIXED-ROUTE BUSES AND LIGHT RAIL TRAINS
What best describes your functional ability to use the fixed-route buses and light
rail trains on your own? (CHECK ALL THAT APPLY)
I can get to and from bus stops/stations if the distance is not too far.
The
severity of my disability or health condition can change from day to day. I can
ride the fixed-route buses and light rail trains when I am feeling well, but not at
other times.
I have a disability or health condition which causes me to be unable to ride the
fixed-route buses and light rail trains if the weather is extremely hot.
I have a disability or health condition which causes me to be unable to ride the
fixed-route buses and light rail trains if the weather is extremely cold.
I am unable to travel on the fixed-route buses and light rail trains when there is rain
and wind due to my disability or health condition.
I cannot climb stairs to get on and off the fixed-route buses and light rail trains, and
need t
he lift/ramp lowered.
Revised October 2017
-
6
-
I can get to and from bus stops only if there are curb-cuts and level sidewalks.
I have difficulty understanding or remembering all the things I would have to do to
use the fixed-route buses and light rail trains.
I can use the fixed-route buses and light rail trains if it is someplace I go all the
time.
I am unable to travel on the fixed-route buses and light rail trains during periods of
dark
ness due to my disability or health condition.
I use RT for some trips, but sometimes I am unable to use the bus or light rail trains
due to high air pollution (smog).
I can never use the fixed-route buses and light rail trains by myself.
I am not really sure if I can use the fixed-route buses and light rail trains by myself.
I am not able to use the fixed-route buses and light rail trains by myself for other
reasons. Please explain:
Revised October 2017
-
7
-
CERTIFICATION OF APPLICANT
I understand the information I provided on this application is true and correct to the best
of my knowledge. The purpose of this application is to determine if I am eligible to use
Paratransit services, or if at times I can ride the RT fixed-route buses and light rail trains.
I understand that falsification of information could result in a loss of Paratransit services
as well as a penalty under the law.
I also understand that, at no expense to me the Regional Transit District may require that
I partic
ipate in an in-person functional evaluation of my travel skills and agree to such a
functional evaluation if one is necessary.
I agree to notify RT if my condition changes, if my mobility device has been replaced, if I
have a new mobility device, or if I no longer need to use Paratransit service.
___________________________________________________ Date_________________
(Signature of Applicant or Guardian if Applicable)
Person Completing Application If Not the Applicant:
Printed Name______________________ Relationship to Applicant_______________
Signature_____________________________________ Date___________________
Daytime Phone #__________________ Evening Phone #__________________
This concludes the applicant’s portion of the
application. The following page MUST be
completed by a Professional.
DO NOT SEPARATE THE APPLICATION FROM THE
PROFESSIONAL VERIFICATION.
BOTH SECTIONS MUST BE MAILED TOGETHER.
Revised October 2017
PROFESSIONAL VERIFICATION (REQUIRED)
To The Applicant - Please have this page completed by a professional before mailing
your application to RT. Any one of the professionals listed below may sign the
application. If this page is not completed and signed by one of the professionals listed
below, the application will be returned to you and processing will be delayed.
MUST BE COMPLETED BY A PROFESSIONAL, NOT THE APPLICANT
To the Professional - Please check your professional title:
physician physician’s assistant registered nurse/nurse practitioner
psychiatrist psychologist case/resource manager
chiropractor physical therapist occupational therapist
certified orientation & mobility specialist
The ADA r
egulations state that persons are eligible for paratransit service if, because of a
disability or medical condition, they are physically or cognitively unable to (not discomforted
by or find difficult) independently use lift-equipped public transit service. ADA paratransit
eligibility is not based on the person’s lack of knowledge of bus service, distance from bus
service, ability to drive, language ability, or age. The information you provide will assist in
determining under what circumstances this applicant may be eligible for paratransit service.
Name of Applicant: _____________________________ DOB _____________
Please describe the medical diagnosis, physical or cognitive disability which causes
the applicant to be unable to independently use a lift-equipped bus or light rail train
some, or all of the time. Must provide specific details or application will be returned:
_________________________________________________________
________
_________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Is this condition temporary? No Yes; for: 4 mos 6 mos 9 mos 12 mos
This person is is not able to self-supervise daily activities
Last date of face-to-face contact with this applicant was______/______ /________
I certify under penalty of perjury under the laws of the State of California that the information
contained in this application is true and correct.
Signature______________________________________ Date _____ /______ /______*
Printed Name_____________________________________ Phone__________________
Clinic/Agency_______________________ Address______________________________
City _________________________________ State _______ ZIP_________________
Professional License/Registration/Certification#_______________ State_______
*This form expires 90 days from the signature date.
Revised October 2017
9
- Form does not need to be typed -
PROFESSIONAL VERIFICATION (REQUIRED)
To The Applicant - Please have this page completed by a professional before mailing
your application to RT. Any one of the professionals listed below may sign the
application. If this page is not completed and signed by one of the professionals listed
below, the application will be returned to you and processing will be delayed.
MUST BE COMPLETED BY A PROFESSIONAL, NOT THE APPLICANT
To the Professional - Please check your professional title:
physician physician’s assistant registered nurse/nurse practitioner
psychiatrist psychologist case/resource manager
chiropractor physical therapist occupational therapist
certified orientation & mobility specialist
The ADA re
gulations state that persons are eligible for paratransit service if, because of a
disability or medical condition, they are physically or cognitively unable to (not discomforted
by or find difficult) independently use lift-equipped public transit service. ADA paratransit
eligibility is not based on the person’s lack of knowledge of bus service, distance from bus
service, ability to drive, language ability, or age. The information you provide will assist in
determining under what circumstances this applicant may be eligible for paratransit service.
Name of Applicant: Jane Doe
Jane DoeJane Doe
Jane Doe
DOB 01/02/1933
01/02/193301/02/1933
01/02/1933
Please describe the medical diagnosis, physical or cognitive disability which causes
the applicant to be unable to independently use a lift-equipped bus or light rail train
some, or all of the time. Must provide specific details or application will be returned:
Patient seen by me one time on
Patient seen by me one time onPatient seen by me one time on
Patient seen by me one time on 3/31/13, 78 years old with below the knee
3/31/13, 78 years old with below the knee 3/31/13, 78 years old with below the knee
3/31/13, 78 years old with below the knee
amputation, LLE gangrene, OA spine / neuropathy / RLE Edema / Severe
amputation, LLE gangrene, OA spine / neuropathy / RLE Edema / Severe amputation, LLE gangrene, OA spine / neuropathy / RLE Edema / Severe
amputation, LLE gangrene, OA spine / neuropathy / RLE Edema / Severe
difficulty with ambulation
difficulty with ambulationdifficulty with ambulation
difficulty with ambulation
Is this condition temporary?
No Yes; for: 4 mos 6 mos 9 mos 12 mos
This person
is is not able to self-supervise daily activities
Last date of face-to-face contact with this applicant was 03
33
3
/
//
/
31
3131
31
/
/ /
/
13
13 13
13
I certify under penalty of perjury under the laws of the State of California that the information
contained in this application is true and correct.
Signature Date 04
4 4
4 /
//
/
1
11
10
0 0
0 /
/ /
/
13
13 13
13 *
Printed Name
Dr. William Smith
Dr. William SmithDr. William Smith
Dr. William Smith
Phone (916) 555
(916) 555 (916) 555
(916) 555-
--
-1234
12341234
1234
Clinic/Agency
ABC Clinic
ABC ClinicABC Clinic
ABC Clinic
Address
1234
1234 1234
1234 7th Avenue
7th Avenue7th Avenue
7th Avenue
City
Sacramento
SacramentoSacramento
Sacramento
State
CA
CACA
CA
ZIP
95814
9581495814
95814
Professional License/Registration/Certification#
A77777
A77777A77777
A77777
State
CA
CACA
CA
* This form expires 90 days from the signature date.
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ADA Para Application Rev8 2017

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Completed 14 August 2020

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