Fillable Connecticut Americans with Disabilities Act (ADA) Paratransit Application (Town of Newtown, CT)

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Connecticut Americans with Disabilities Act (ADA) Paratransit Application (Town of Newtown, CT)

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CT_ADAApplication_Rev4 7/2016
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Connecticut Americans with Disabilities Act
(ADA)
Paratransit Application
Form
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Instructions for Submission
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To request a copy of this application in an accessible format, please call (203) 365-
8522 Extension 273.
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The purpose of this application is to determine eligibility for Connecticut
complementary ADA Paratransit service. If you have a disability that prevents you
from using the public transit bus service in Connecticut, you may be eligible for
ADA Paratransit service. ADA Paratransit is a shared ride, advanced reservation,
origin-to-destination service for persons with disabilities who are unable to use the
public bus service because of their disability.
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Service Criteria
The Connecticut ADA Paratransit program is designed to meet the Americans with
Disabilities Act service criteria established by the federal government. Service is
provided only to individuals found eligible by a Connecticut regional ADA service
provider and is operated under the following ADA guidelines:
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Complementary service is only provided in areas where public buses operate.
This does not include Express Commuter service, Intercity or Dial-A-Ride
services. ADA Paratransit vehicles can only make pick-ups and drop-offs at
places that are within three-quarters of a mile of a public bus route.
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Service is provided only during the hours and days when public bus service
in that area operates.
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Rides must be reserved at least one day in advance.
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ADA Paratransit fares are typically double the cost of a full fare on a public
bus route.
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Service is not restricted by trip purpose but provided for all types of trips.
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ADA Definition of Disability
Any person with a disability who is unable, as a result of a physical or mental
impairment, and without the assistance of another individual (except the
operator of a wheelchair lift), to board, ride, or disembark from any public bus.
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Any person with a disability who has a specific impairment-related condition
which prevents them from traveling to or from a bus stop on the public bus system.
CT_ADAApplication_Rev4 7/2016
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Architectural and environmental barriers such as distance, terrain or weather; do
not form a basis for eligibility alone. However, a person may be eligible if the
interaction of the disability and environmental barriers prevent the person from
traveling to or from the public bus stop.
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Types of Eligibility
There are three types of eligibility:
Unconditional Eligibility - Your disability or health condition always
prevents you from using public buses and you qualify for ADA Paratransit
service for all of your trips.
Conditional Eligibility - You are able to use the public buses for some of
your trips and qualify for ADA Paratransit service for other trips when your
disability or environmental barriers prevent the use of public bus service.
Temporary Eligibility - You have a health condition or disability that
temporarily prevents you from using the public bus.
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Application Process
ADA Paratransit service is provided for customers whose disability or health
condition may prevent them from using public bus services for some or all of their
travel. Individuals who are interested in using ADA Paratransit service must apply
and be found eligible according to ADA guidelines. Regional ADA Paratransit
service providers determine an individual's functional abilities and limitations for
using public bus services. A list of service providers in Connecticut is attached to
this application see “ATTACHMENT A”.
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To apply for ADA Paratransit eligibility, contact the regional ADA Paratransit
service provider or visit www.CTADA.com.
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Once you have filled out as much of the application as you can and submitted it by
mail or online to your regional service provider, allow seven (7) days
and then call your provider to set up your certification interview (a list of service
providers in Connecticut is attached to this application see “ATTACHMENT A”).
If needed, transportation to the interview will be provided and the services of an
American Sign Language or other language interpreter offered at no charge.
Please bring an acceptable form of identification with you (preferably a photo ID) to
the interview. If you do not have a photo ID available, contact your service provider
to determine acceptable forms of identification. You may also bring additional
information about your disability or health condition, but this is not required.
CT_ADAApplication_Rev4 7/2016
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During the interview, your application form will be reviewed and if necessary,
assistance will be offered to help you complete it. Your travel abilities and
limitations will be discussed in more detail. You may be asked to take a "mock"
bus trip. This will take about 30 to 45 minutes and your travel abilities and
limitations will be assessed. Please dress for the weather as you may be asked to go
outside. Also, at the interview you may be asked to sign a document allowing the
service provider to contact your physician or other professional to verify your
eligible condition. Finally, at the interview you will be asked to sign a certificate
that the information in your application is true and correct. Providing false and
misleading information may result in a reevaluation of your eligibility.
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A decision will be made on your application within 21 days after the completion
of the interview, assessment and receipt of medical verification and follow-up
questions, if necessary. If a decision is not made within 21 days, temporary
eligibility and ADA Paratransit service will be provided until a final decision is
made. You will be notified of your eligibility by letter.
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If you are determined to be eligible for ADA Paratransit for some or all of your
trips, you will receive a Certification Letter and a Customer Guide with
information about how to use the service.
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Appeal Process:
If you are determined to be able to use public buses for some or all of your trips,
you will be notified of the exact reason(s) for this decision and told how you may
appeal the decision.
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You can appeal any eligibility decision made by the regional service provider that
limits your ability to use ADA Paratransit service. For example:
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You were found "Not Eligible" for ADA Paratransit
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You were found "Conditionally Eligible" and disagree with the eligibility
categories you were given or you think the conditional status is wrong.
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All requests for an appeal must be in writing and should be mailed to your regional
service provider.
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If you have any questions about the application process, contact your regional
ADA Paratransit service provider.
CT_ADAApplication_Rev4 7//2016
Page 1
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Connecticut Americans with
Disabilit
ie
s
Paratransit Application
Fo
r
m
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This form is also available online at www.CTADA.com
Please note that any information given on this application will be kept confidential and shared
only with professionals involved in providing the paratransit service on an as needed basis.
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THIS APPLICATION WILL BE ACCEPTED AT ANY ADA PARATRANSIT
PROVIDER IN THE STATE OF CONNECTICUT
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A. Personal Information
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Mr.
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Mrs.
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Ms.
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Last Name:
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First Name:
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B. Current Residence
Street
Address:
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Building:
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Apartment:
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Room:
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City:
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State:
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Zip:
Is this residence:
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A Single or Multi-Family House
An Apartment or
Condominium Complex
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Name:
A Nursing or Assisted
Living Facility
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Name:
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Other:
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Is this a temporary residence:
Yes
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No
C.
Mailing
Address
(if
different
from
residence)
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Street Address or P.O. Box:
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Building:
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Apartment:
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Room:
City:
State:
Zip:
CT_ADAApplication_Rev4 7//2016
Page 2
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D. Contact Information
Primary
Phone:
Alternate
Phone:
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TDD or Relay Number:
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Email Address:
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E. Emergency Contact
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Last Name:
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First Name:
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Relationship:
Agency if
Applicable:
Primary
Phone:
Alternate
Phone:
F. If someone assisted you in completing this form please give the
following information:
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Last Name:
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First Name:
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Relationship:
Agency if
Applicable:
Primary
Phone:
Alternate
Phone:
G. General Information
Do you need ADA service information in an
accessible format?
Yes No
If “yes”, please indicate which format would be helpful:
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Large Print
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Audio Recording
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Braille
Other
Are you certified for ADA paratransit services by
another service provider or transit agency?
Yes No
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If, yes:
Name of
Service
Provider:
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State:
ID number:
(if
applicable)
Page 3
CT_ADAApplication_Rev4 7/2016
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H. Information About Your Disability
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Please list by name what disabilities or health related conditions prevent you from
using the public bus service:
Explain how your disabilities or health related conditions prevent you from
independently using the public bus service?
Do you use any of the following when you travel?
Manual Wheelchair *
Scooter *
Powered Wheelchair *
Cane
Walker
Communication Device
Oxygen If yes:
Crutches
Tank Compressor
Service Animal
Respirator
Medical Equipment
Other, explain:
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*The term wheelchair refers to any three or more wheeled device utilized which is
usable indoors. We will be able to accommodate a wheelchair if (1) the lift and
vehicle can physically accommodate it and (2) if it is consistent with legitimate
safety requirements. Legitimate safety requirements include but are not limited to
such circumstances as a wheelchair of such size that it would block an aisle, or
would interfere with the safe evacuation of passengers in an emergency.
Page 4
CT_ADAApplication_Rev4 7//2016
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H. Information About Your Disability (continued)
Is the disability or health related condition you describe:
Permanent
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Temporary
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Expected to last Months
Unsure
Does your health condition or disability change from day to day in a way that
affects your ability to use the public bus service?
Yes
No
Sometimes
If “Yes” or
"Sometimes",
Please explain:
Are there times when someone accompanies you when you travel?
Yes
No
Sometimes
I. Public Bus Service Experience
Have you ever ridden the public bus?
Yes If yes, how often and to what locations?
No If no, why don’t you currently ride the public bus?
Travel training is a free service that teaches people how to use the public bus.
Would you like more information about this service?
Yes
No
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CT_ADAApplication_Rev4 7/2016
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J. Functional Ability
Can you find your way to a public bus stop if someone shows you once?
Yes
No
Sometimes
How far can you walk (using a mobility aid if necessary)?
Can you walk up/down a gradual hill?
Yes
No
Sometimes
Can you see/detect curbs, ramps and other drop off areas?
Yes
No
Sometimes
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How long can you stand and wait at a public bus stop?
Can you get on and off a public bus?
Yes
No
Sometimes
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If “No” or “Sometimes”, please explain:
Can you ask for, understand, and follow travel directions.
Yes
No
Sometimes
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If “No” or “Sometimes”, please explain:
K. Barriers
What barriers in the environment would make it difficult for you to use the public
bus service?
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Lack of curb cuts Steep Hills
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Busy street I must cross No crosswalk light
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No sidewalks Sidewalks in poor condition
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Other, describe:
Explain why the conditions you indicated make it difficult to use the public bus
service
CT_ADAApplication_Rev4 7/2016
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AUTHORIZATION TO
OBTAIN
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PHYSICIAN OR OTHER PROFESSIONAL
VERIFICATION
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After the interview, the local ADA paratransit provider may need to contact a
physician or a professional familiar with your disability. Please provide the
following information for a physician or professional who is able to
provide the
needed information that would help determine eligibility for ADA
paratransit service provider. You do not need to have the professional sign this
form.
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Physician
Health Care
Professional
Rehabilitation
Professional
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Professional’s Name:
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Agency:
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Office Address:
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City:
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State:
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Zip:
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Phone:
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Office Fax:
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Applicant’s Name:
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Date of Birth:
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Signature of applicant or guardian:
Applicant agrees to share the application information with other service providers
within the State of Connecticut
?
Yes
No
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CT_ADAApplication_Rev4 7/2016
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ADA Definition of Disability
Any person with a disability who is unable, as a result of a physical or mental impairment,
and without the assistance of another individual, (except the operator of a wheelchair lift) to
board, ride, or disembark from any public city bus.
Any person with a disability who has a specific impairment-related condition which
prevents them from traveling to or from a bus stop on the public city bus system.
Architectural and environmental barriers such as distance, terrain or weather; do not form a
basis for eligibility alone. However, a person may be eligible if the interaction of the
disability and environmental barriers prevent the person from traveling to or from the public
bus stop.
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DO NOT SIGN THIS PAGE NOW OR SUBMIT WITH YOUR
APPLICATION.
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THIS PAGE MUST BE SIGNED IN PERSON AT THE INTERVIEW.
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I understand that the purpose of this application is to determine if there are
times when I cannot use the public bus service and must therefore use ADA
paratransit services. I certify that to the best of my knowledge, the information
in this application is true and correct. I understand that providing false or
misleading information may result in a reevaluation of my eligibility.
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Signature of Applicant or Guardian
Date
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CT_ADAApplication_Rev4 7/2016
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PLEASE NOTE:
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Thank you for completing the Connecticut Americans with Disabilities
Paratransit Application form.
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Once you have filled out as much of the application as you can and submitted it
to your regional service provider, allow seven (7) days and then call your provider
to set up your certification interview. If needed, transportation to the interview
will be provided and the services of an American Sign Language or other
language interpreter offered at no charge. Please bring an acceptable form of
identification with you (preferably a photo ID) to the interview. If you do not
have a photo ID available, contact you service provider to determine acceptable
forms of identification. You may also bring additional information about
your disability or health condition, but this is not required.
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Page 7
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Connecticut Americans with Disabilities Act (ADA) Paratransit Application (Town of Newtown, CT)

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