Fillable ROUND ROCK TEXAS TRANSIT (City of Round Rock, Texas)

Fill Online, Printable, Fillable, Blank ROUND ROCK TEXAS TRANSIT (City of Round Rock, Texas) Form

Use Fill to complete blank online CITY OF ROUND ROCK, TEXAS (TX) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

ROUND ROCK TEXAS TRANSIT (City of Round Rock, Texas)

On average this form takes 28 minutes to complete

The ROUND ROCK TEXAS TRANSIT (City of Round Rock, Texas) form is 35 pages long and contains:

  • 0 signatures
  • 36 check-boxes
  • 94 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Round Rock, Texas

BROWSE CITY OF ROUND ROCK, TEXAS (TX) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
ROUND
ROCK
TEXAS
TRANSIT
City of Round Rock
ADA Complementary
Paratransit Service Plan
Grantee ID: 6631
February 28, 2017
Table of Contents
Identification of Entity.................................................................................................................... 3
Mission............................................................................................................................................ 3
Background ..................................................................................................................................... 3
Nondiscrimination........................................................................................................................... 4
Filing an ADA Complaint............................................................................................................... 4
Description of Fixed Route System ................................................................................................ 5
Eligibility Requirements and Application Process ......................................................................... 5
Application Denial Appeal Process ................................................................................................ 6
Service Type ................................................................................................................................... 6
Service Area and Hours of Operation............................................................................................. 7
Reservations.................................................................................................................................... 7
Return Trips .................................................................................................................................... 7
Subscription Trip Policy ................................................................................................................. 7
No-show Policy............................................................................................................................... 8
No-Show Service Suspension Appeals Process.............................................................................. 9
Pick-up Times and Passenger Readiness ........................................................................................ 9
Traveling Companions of ADA Eligible Persons......................................................................... 10
Trip Purpose.................................................................................................................................. 10
Service Animals, Mobility Devices, and Other Necessary Equipment ........................................ 10
Lift and Securement Use Policy ................................................................................................... 10
Capacity Constraints ..................................................................................................................... 11
Fare Structure................................................................................................................................ 11
Rider Behavior .............................................................................................................................. 11
Packages........................................................................................................................................ 11
Visitors.......................................................................................................................................... 11
Public Participation Process.......................................................................................................... 11
Accessible Formats ....................................................................................................................... 12
Attachment A - Complaint Forms................................................................................................. 13
Attachment B - Fixed Route Maps ............................................................................................... 24
Attachment C - ADA Paratransit Service Application ................................................................. 27
Identification of Entity
Name: City of Round Rock
Address: 2008 Enterprise Drive
Round Rock, Texas 78664
Contact: Caren Lee, Transit Coordinator
Phone: 512-671-2869
Fax: 512-218-5536
Mission
The mission of City of Round Rock Transit is to provide quality and efficient paratransit service to
passengers while complying with the Americans Disabilities Act (ADA).
Background
The Americans with Disabilities Act of 1990 (ADA) requires public entities who operate non-commuter
fixed route transportation services must also provide complementary paratransit service. The ADA
requires the complementary paratransit service be comparable to the fixed route service, in terms of
service levels and availability. There are six minimum service standards used to evaluate the
comparability of the complementary paratransit service to the fixed route service.
1. Availability in the same area served by the fixed route. Specifically, service must be made
available to all origins and destinations within a minimum width of ¾ of a mile on each side
of each fixed route. This includes an area within ¾ miles radius at the end of each fixed route
as well;
2. Available to any ADA Paratransit eligible persons at any requested time on anyparticular
day in response to a request for service made the previous day;
3. Paratransit Service’s fares that are no more than twice the fare that would be charged to an
individual paying full fare for a trip of similar length, at a similar time of day on the fixed
route system;
4. There can be no trip restrictions or priorities based on trip purpose;
5. Service must be made available to eligible persons on a next day basis; and
6. There can be no constraints on the amount of service that is provided to any eligible person.
Specifically, there can be no operating practice that significantly limits the availability of
service to individuals.
Transit providers subject to the ADA regulations must develop and administer a process for determining
a person’s eligibility for the complementary paratransit service. ADA Paratransit service must be
provided to all individuals who are unable, because of their disability, to use the fixed route system,
some of the time or all of the time. The criteria for determining a persons’ eligibility is regulated by the
ADA and it requires the City to have a documented process.
3
Nondiscrimination
The City of Round Rock shall not discriminate against an individual with a disability in connection with
the provision of transportation service. The City shall not deny, to any individual with a disability, the
opportunity to use the City’s transportation service for the general public, if the individual is capable of
using the service. The City shall not require an individual, with a disability, to use designated priority
seats, if the individual does not choose to use those seats.
Filing an ADA Complaint
Any person who believes they have been discriminated against on the grounds of disability may file a
complaint directly with the Federal Transit Administration (FTA) or with the City. Complaints should
be filed within 180 days of the alleged violation.
To file a complaint with FTA, complete the FTA complaint form, found in Attachment A. The
complaint form must be signed and mailed to:
Federal Transit Administration
Office of Civil Rights
Attention: Complaint Team
East Building, 5th Floor – TCR
1200 New Jersey Avenue, SE
Washington, DC 20590
With your form, please attach on separate sheet(s):
A summary of your allegations and any supporting documentation.
Sufficient details for an investigator to understand why you believe a public transit provider has
violated your rights, with specifics such as dates and times of incidents.
Any related correspondence from the transit provider.
To file a complaint with the City, complete the City’s complaint form, found in Attachment A. The
complaint form must be signed and mailed to:
City of Round Rock
Attn: Transit Coordinator
2008 Enterprise Drive
Round Rock, Texas 78664
Within 5 business days of the receipt of the complaint, the Transit Coordinator will notify, in writing,
the complainant and FTA of the receipt of the complaint. The Transit Coordinator will review the
complaint, policies and procedures associated with the complaint, and the circumstances under which
the alleged discrimination occurred and any other pertinent factors.
Within 30 days of the receipt of the complaint, the Transit Coordinator will send the complainant and
FTA a letter of finding. The letter of finding will outline the results of the investigation. If the
4
investigation determines the City is not in violation, the letter of finding will include an explanation and
provide notification of the complainant’s appeal rights. If the investigation determines the City is in
violation, the letter of finding will document the violation and the action the City will take or has taken
to resolve the violation.
Description of Fixed Route System
The City of Round Rock’s (City) Transit System consists of two local fixed routes. The service operates
Monday – Friday, 6:30 a.m. to 6:30 p.m., with hourly headways. Each of the fixed routes serve the
Intermodal Transit & Parking Facility (ITPF). Maps of the two fixed routes are included in Attachment
B. Route 50, RR/Howard, operates in a north and south pattern on the east side of IH-35; it begins at the
higher education center, runs through town, and ends at Capital Metro’s Howard Lane MetroRail
Station. Route 51, RR Circulator, operates in an east and west pattern serving the medical complexes on
RM 620 and the Dell/Walmart/Target area; it begins and ends at the ITPF.
Each route will be operated with two vehicles, for a total of four vehicles. As required by the ADA all
routes and vehicles are accessible by persons with disabilities. Maintenance of accessible features on
vehicles, as required by the ADA is maintained to a high level, so persons needing these features receive
equivalent service. If for some reason the lift or other accessible features, is not working, another
accessible feature equipped vehicle will be provided within 30 minutes. Bus operators will also make
major stop announcements.
Eligibility Requirements and Application Process
The following individuals are ADA paratransit eligible:
1. any individual with a disability who is unable to ride or disembark from any fixed route vehicle,
OR
2. any individual whose specific disability makes it impossible for them to travel independently all
or some of the time on a fixed route
An individual interested in riding City of Round Rock’s paratransit service will submit a completed
application to the Transit Coordinator at:
Transportation Department
Attn: Transit Coordinator
2008 Enterprise Drive
Round Rock, Texas 78664
The completed application will include a healthcare professional attesting to the passenger’s disability
and that such disability would prevent the passenger’s ability to independently travel on the fixed route
service either all of the time or some of the time. The application is included as Attachment C.
A healthcare professional authorized to complete the healthcare provider verification section of the
application include, doctors of medicine, doctors of osteopathic medicine, doctors of chiropractic,
registered nurses, physician assistants, nurse practitioners, certified nurse specialist, certified registered
nurse anesthetists, clinical social worker, and physical, speech, occupational, and massage therapists.
5
You will receive your eligibility determination within 21 calendar days from the date ALL of the
following are completed:
Full application and verification received
In-person eligibility review
Any additional requested information is received by staff
Any applicant who has completed the above steps but has not received an eligibility
determination letter, within 21 days, will be entitled to unlimited use of the paratransit
service until you are notified your eligibility determination.
The applicant will be notified in writing of the applicant’s eligibility. If approved, the passenger will be
added to the eligibility list and will be able to start scheduling rides. If denied, the individual has the
right to appeal that decision.
Having a disability does not automatically qualify you for ADA Paratransit Service.
Application Denial Appeal Process
If your application for ADA Paratransit Service is denied, you will need to submit your appeal, in
writing, within sixty (60) days of the date of the denial notice. Appeals should be sent to:
Transportation Department
Attn: Transit Coordinator
2008 Enterprise Drive
Round Rock, Texas 78664
Upon receipt of your desire to appeal, Round Rock Transit will schedule a meeting with the designated
individual(s) to hear your appeal. You will be notified by mail of the date and time of this meeting.
You will have the opportunity to submit additional information, written evidence and/or arguments to
support your qualifications for ADA Paratransit service. You may bring a representative with you to
this meeting.
You will be notified of the designated individual(s) decision, in writing, within 30 days of the meeting.
Their decision is final.
Service Type
The City provides an origin to destination paratransit service, including:
Feeder service to an accessible fixed route, where such service enables the individual to use the
fixed route bus system for part of the trip
Curb-to-curb, shared ride, service
Passengers should wait for the vehicle in a location where the vehicle can be seen, and preferably where
the bus operator can see the passenger. Passengers will be dropped off in a safe location, as close as
possible to the entrance of your destination.
6
If a passenger needs assistance beyond the curb, it shall be provided as long as the assistance does not
result in the following:
A direct threat
The bus operator cannot see the vehicle from the door, typically no further than 75 feet from the
vehicle
The bus operator entering the passengers home or other pick-up and drop-off locations
The bus operator backing the vehicle
The vehicle impeding or blocking traffic
If you live in a gated community, it is your responsibility to provide the gate code when making the
reservation. If you live in an apartment complex, the pick-up location is in front of the leasing office. If
a passenger cannot traverse to the leasing office, the passenger may be picked up in front of their
building, upon request.
Service Area and Hours of Operation
The City offers ADA Complementary Paratransit within the required ¾ mile radius of each bus route,
including the beginning and ending points. Adjustments to this service area will be made on a case-by-
case basis and not extend beyond the city limits or the extraterritorial jurisdiction of the City.
Paratransit Service will be provided the same days and hours as the City’s Transit Service, which is
Monday – Friday, 6:30 a.m. – 6:30 p.m. The Transit Service does not operate on major holidays.
Reservations
Reservations are taken Monday through Friday during normal business hours, 8:00 a.m. to 5:00 p.m.,
except on designated holidays or weekends. Reservations can be made up to two weeks in advance.
Next-day service is provided for requests made, any time, during the preceding day, prior to 4:00 p.m.,
Monday through Friday.
On days when the offices are closed and no reservations can otherwise be made and when the following
day is a service day, an answering machine or similar recording device is available to patrons for
scheduling or canceling reservations. At opening of next business day, all messages will be checked and
calls returned to confirm reservations or cancellation.
Return Trips
Passengers will be asked, at time of initial reservation, to schedule a return time, if necessary.
Subscription Trip Policy
Passengers who use the paratransit service to make regular, recurring, trips can request a standing
reservation, referred to as a subscription trip, through the dispatch office. The ADA does not allow more
than 50% of its service to be subscription in nature. Subscription trips will be limited to no more than
50% of complementary paratransit service capacity. The City will take subscription requests on a first-
come-first-serve basis.
7
If a passenger makes a standing reservation and has three (3) no-shows, per the City’s no-show policy,
the standing reservation will be cancelled and that passenger will not be eligible to qualify for
subscription service for three (3) months. Trips missed by the individual for reasons beyond his or her
control, including, but not limited to, trips that are missed due to operator error, will not count as a no-
show.
No-show Policy
No-shows, as well as late cancellations, result in wasted trips which could have been used by other
passengers. It is the policy of Round Rock Transit to record each customer’s no-show(s) and apply
appropriate sanctions when customers establish a pattern of excessive no-shows. The policy is necessary
in order to recognize the negative impact no-shows have on the services provided to other passengers.
A no-show is defined as:
any time a bus operator goes to pick a customer up and
o he or she decides not to use the service
o is not at the pickup location
o has not called to cancel their trip at least one (1) hour before the scheduled pick-up
time
o has waited the required 5 minutes and the passenger does not board the vehicle
Passenger no-shows for reasons that are beyond the passengers control will not be counted. Examples of
excused no-shows include, but are not limited to:
illness,
accidents,
family emergency,
passenger’s appointment ran longer than expected and customer could not call to cancel, or
Acts of God (flood, earthquake, etc.).
Passengers should contact reservations as soon as possible to alert them of your emergency so your
missed trip is not counted as a no-show.
Round Rock Transit schedules pick-ups and return trips separately. We will assume all scheduled return
trips are needed unless notice is given by the passenger.
If a passenger is a no-show for the first trip of the day, Round Rock Transit will not automatically cancel
subsequent trips of the day. If, however, the passenger does not need the return or other subsequent
trip(s), they will need to cancel them as soon as possible out of courtesy for other riders. If subsequent
trips are not cancelled the passenger will be charged with a no-show.
If a passenger has been transported to their destination, but who is a no-show when the bus returns, they
must call dispatch to request a return trip, however a pick-up window will not be guaranteed.
Suspensions of service will occur when a rider exceeds the maximum number of no-shows allowed per
month. Table 1 and Table 2 outline the maximum number of no-shows allowed per number of trips
scheduled and the associated penalties for violations.
8
-
-
If your service is suspended you will be sent a Notice of Service Suspension, to your home address on
file. The Notice will include dates of suspension, a no-show report, appeal process and a copy of this
Policy.
Table 1
Trips Scheduled
per Month
Maximum # No Shows
Allowed per Month
1 to 14
2
15 to 39
4
40 to 59
6
60 +
8
Table 2
No Show Penalties
First violation
Letter of warning
Second violation
3 day suspension
Third and Fourth violation
15 day suspension
No-Show Service Suspension Appeals Process
If you have been suspended from service and feel the information regarding your no-show(s) is
incorrect, you have the right to submit an appeal.
All appeals must be submitted in writing, to the City at:
Transportation Department
Attn: Transit Coordinator
2008 Enterprise Drive
Round Rock, Texas 78644
within 15 days of the date of the Notice of Service Suspension letter. The appeal should provide the
reason you feel your service should not be suspended. Appeals will be reviewed by the City and you
will be notified of the City’s decision within 10 days of receipt of the appeal.
Pick-up Times and Passenger Readiness
Passengers are given an approximate pick-up time, to allow for the best use of resources. Bus operators
strive to maintain prompt schedules to ensure all passenger reservations are honored. Passengers are
asked to allow a 30-minute window of time for arrival. The 30-minute window means the passenger
needs to be ready to board the vehicle 15 minutes before and 15 minutes after the scheduled time.
Upon vehicle arrival, within the 30-minute window, passengers have five (5) minutes to board the bus.
Dispatch may contact the passenger if the vehicle is going to be earlier or later than the 30-minute
9
window, as there may be times when outside factors affect the vehicle’s arrival time, such as traffic and
road conditions.
Traveling Companions of ADA Eligible Persons
Personal care attendants are eligible to accompany the ADA eligible person at no charge. Passengers
are required to reserve a space, at the time of reservation, for a personal care attendant. In addition, the
need of a personal care attendant needs to be disclosed during the application process. If the use of a
personal care attendant is not disclosed, then any individual accompanying the ADA eligible person
shall be regarded as a companion.
Companions, who are not acting in the capacity of a personal care attendant, with the same origin and
destination, are allowed to travel with the ADA eligible person on a space available basis. Companions
are required to pay the applicable paratransit fare.
Trip Purpose
The City will accept and handle all trip requests on an equal basis. The City will not prioritize or restrict
trip purposes for paratransit riders.
Service Animals, Mobility Devices, and Other Necessary Equipment
The City shall not prohibit any mobility device, provided it does not exceed the capacity of the vehicle
or its equipment (lifts/ramps).
The City shall not prohibit a passenger from boarding who has a respirator, portable oxygen and/or other
life support equipment, as long as the items do not violate the law or rules relating to the transportation
of hazardous materials. All equipment must be small enough to fit in the vehicle safely without
obstructing the aisle or blocking emergency exits.
All passengers are allowed to travel with service animals trained to assist them.
Lift and Securement Use Policy
In accordance with ADA regulations, Round Rock Transit will provide service to all individuals using
mobility devices that fit within the capacity of the lift being operated. Passengers are advised that bus
operators are not permitted to operate a mobility device onto the lift. The passenger is responsible for
getting onto the lift with minimal bus operator assistance for these devices.
Use of the securement system is required as a condition of service. All wheelchairs and mobility devices
must be safely secured before transport. When transporting passengers using mobility devices, Round
Rock Transit can suggest but not require passengers transfer to a seat. The passenger, in this case, has
the final decision as to whether a transfer is appropriate given the passengers’ particular disability.
As the regulations require, a passenger who cannot enter the vehicle using the stairs or ramp, but who
does not use a wheelchair, will be allowed to enter the vehicle using the lift. Round Rock Transit does
not provide wheelchairs or other mobility devices.
10
Capacity Constraints
Service will not be limited because of capacity constraints. No waiting lists will be maintained and the
number of trips provided to an individual will not be restricted. Reservation times may be negotiated
within one hour before and after the requested pickup time.
Fare Structure
The regular fares for fixed routes is shown in Table 3. The paratransit fares will be no more than twice
the regular fare, per federal regulations, and will be adjusted in conjunction with changes in fixed route
fares. The City shall not impose any special charges for providing services to persons with a disability.
Table 3
Fare
Regular
ADA
Type
Fare
Paratransit Fare
Single Ride
$1.25
$2.00
Day Pass
$2.50
$5.00
Rider Behavior
Passengers are expected to conduct themselves in a respectable manner. Unruly, violent or illegal
conduct will not be tolerated and will be dealt with promptly, including but not limited to expulsion
from the vehicle and/or notifying law enforcement.
Packages
Passengers are expected to only bring what they can safely carry on their own or with the assistance
from a personal care attendant or companion, in one trip. Packages cannot block the aisle or pose a
safety hazard.
Visitors
Individuals who are visiting the Round Rock area are eligible to use Round Rock Transit’s ADA
Paratransit service if they provide roof of disability from the area in which they reside. This service is
available for a total of 21 days per calendar year. If the individual exceeds 21 days, then that person will
be required to submit the Round Rock Transit’s ADA Application.
Public Participation Process
The City will solicit the public’s input prior to implementation of this ADA Complementary Paratransit
Service Plan. The City will conduct public meetings, accept emails and phone calls. Notices of the
available methods to provide input will be posted on the City’s website, social media sites and the local
newspaper. All comments and input will be taken under consideration. The final plan will be presented
to City Council for approval.
11
Accessible Formats
The information in this policy and all other materials related to Round Rock Transit's programs will be
made available in an accessible format upon request.
12
Attachment A - Complaint Forms
13
City of Round Rock
Civil Rights Complaint Form
Section 1 – Basic Information
Last Name First Name MI
Street Address Apt # Gate Code
City/State/Zip
Date of Birth Email
Primary Phone Number ☐Home ☐Cell ☐Work
Secondary Phone Number ☐Home ☐Cell ☐Work
Section 2 – Complaint Information
1. Please select at least one of the following as the basis of your complaint:
☐Race ☐Age ☐National Origin
☐Color ☐Gender ☐Disability
2. What was the date and place of the alleged discriminatory action(s)? Please include, at a minimum, the
earliest and most recent date.
3. Please describe how you were discriminated against, explaining as clearly as possible why you believe your
Title VI rights were violated. Attach additional pages, if necessary.
4. Please provide the name(s) of individual(s) responsible for the alleged action described above.
5. Please provide the name(s) of person(s) whom we may contact for additional information to support or
clarify your complaint.
Name
Address
Telephone #
6. Briefly explain what action or remedy you are seeking for the alleged discriminatory action.
7. Attach any relevant documentation you believe will assist with an investigation.
Section 3 – Filing Information
1. Have you filed this complaint with any of the following agencies?
U.S. Department of Transportation ☐Yes ☐No
U.S. Department of Justice ☐Yes ☐No
Federal Transit Administration ☐Yes ☐No
Federal Highway Administration ☐Yes ☐No
Texas Department of Transportation ☐Yes ☐No
Equal Employment Opportunity Commission ☐Yes ☐No
Other ☐Yes ☐No
If yes, please provide a copy of the complaint form you filed with any of the above agencies.
2. Is this complaint against the City of Round Rock? ☐Yes ☐No
3. Have you been in contact with a City employee regarding this complaint? ☐Yes ☐No If yes, what is the
name and telephone number of the employee?
4. Have you filed a lawsuit regarding this complaint? ☐Yes ☐No
Section 4 - Certification
I certify all the information contained in this complaint is true and correct to the best of my knowledge.
Signature Date
Authorized Representative Information
Name Phone Number
Relationship to the Applicant
Signature Date
Please mail your completed form to:
Transportation Department
Attn: Title VI Complaints
2008 Enterprise Dr.
Round Rock, Texas 78664
{NOTE: The City cannot accept this complaint form without a signature.}
City of Round Rock
Formulario de Queja de Derechos Civiles
Seccion 1 – Información basica
Apellido Primer Nombre Segundo Nombre
Dirección Apt # Código del portón
Cuidad/Estado/Zona postal
Fecha de nacimiento Correo electrónico
Número de teléfono primario ☐Casa ☐Móvil ☐Trabajo
Número de teléfono secundario ________ ☐Casa ☐Móvil ☐Trabajo
Seccion 2 – Informacion de Quejas
1. Por favor seleccione al menos uno de los siguientes como base de su queja:
☐Raza ☐Edad ☐Origen Nacional
☐Color ☐Genero ☐Discapacidad
2. ¿Cuál fue la fecha y el lugar de la supuesta (s) acción (es) discriminatoria (s)? Por favor incluya,
como mínimo, la fecha más temprana y más reciente.
3. Describa cómo fue discriminado, explicando con la mayor claridad posible por qué cree que sus
derechos de Título VI fueron violados. Adjunte páginas adicionales, si es necesario.
______
____________
______
4. Por favor indicar el (los) nombre (s) de los individuos responsables de la supuesta acción descrita
anteriormente.
5. Por favor proporcionar el nombre de la (s) persona (s) a quienes podemos contactar para obtener
información adicional para apoyar o aclarar su queja.
Nombre
Direccion
Telefono#
6. Explique brevemente qué acción o recurso usted está buscando para la supuesta acción
discriminatoria.
7. Adjunte cualquier documentación pertinente que crea que le ayudará en una investigación.
Seccion 3 – Informacion de archivo
1. ¿Ha presentado esta queja ante alguna de las siguientes agencias?
U.S. Department of Transportation ☐Sí ☐No
U.S. Department of Justice ☐Sí ☐No
Federal Transit Administration ☐Sí ☐No
Federal Highway Administration ☐Sí ☐No
Texas Department of Transportation ☐Sí ☐No
Equal Employment Opportunity Commission ☐Sí ☐No
Otro ☐Sí ☐No
En caso afirmativo, proporcione una copia del formulario de quejas que presentó ante cualquiera de
las agencias mencionadas.
2. ¿Es esta queja contra la Ciudad de Round Rock? ☐Sí ☐No
3. Ha estado en contacto con un empleado de la Ciudad con respecto a esta queja? ☐Sí ☐No
En caso afirmativo, ¿cuál es el nombre y número de teléfono del empleado?
4. ¿Ha presentado una demanda relacionada con esta queja? ☐Sí ☐No
Seccion 4 - Certificación
Certifico que toda la información contenida en esta queja es verdadera y correcta según entiendo.
Firma Fecha
Información del Representante Autorizado
Nombre Teléfono
Relación con el solicitante
Firma Fecha
Envíe por correo su formulario completado a:
Transportation Department
Attn: Title VI Complaints
2008 Enterprise Dr.
Round Rock, Texas 78664
{NOTA: La Ciudad no puede aceptar este formulario de queja sin una firma.)
L£A
T
exu
~partment
Tr.msporta
tion
External
Discrimination
Complaint
Form
Form 2193
(Rev. 09/10)
Page 1 of 2
Mail the signed form to Texas Department of Transportation, Office
of
Civil Rights,
125 East 11th Street, Austin, Texas 78701 or fax to 512/416-4751 .
Last Name
First Name
Mailing Address
City
I State
Zip
Telephone
I Alternate Telephone
E-mail Address
Please indicate the basis
of
your complaint:
D Race
0Age
D National Origin
D Color
D Gender
D Disability
Date and place
of
alleged discriminatory action(s). Please include the earliest date of discrimination
and
the most
recent date
of
discrimination.
How were you discriminated against? Describe the nature
of
the action, decision, or conditions of the alleged
discrimination. Explain as clearly as possible what happened and why you believe your protected status (basis) was
a factor
in
the discrimination. Include how other persons were treated differently from you. (Attach additional pages,
if necessary).
The law prohibits intimidation or retaliation against anyone because he/she has either taken action, or participated
in
action, to secure rights protected by these laws. If you feel that you have been retaliated against, separate from the
discrimination alleged above, please explain the circumstances below. Explain what action you took which you
believe was the cause for the alleged retaliation.
Names
of
individuals responsible for the discriminatory action(s):
Form 2193 (Rev.
09/1
O)
Page 2
of
2
Names of persons (witnesses, fellow employees, supervisors, or others) whom we may contact for additional
information to support or clarify your complaint: (Attach additional pages, if necessary).
Name
Address
Telephone
1.
2.
3.
4.
Have you filed, or intend to file, a complaint regarding the matter raised with any of the following? If yes, please
provide the filing dates. Check all that apply.
D U.S. Department of Transportation
D Federal Highway Administration
D Federal Transit Administration
D Office
of
Federal Contract Compliance Programs
D U.S. Equal Employment Opportunity Commission
D U.S. Department of Justice
D Other
Have you discussed the complaint with any TxDOT representative? If yes, provide the name, position,
and
date of
discussion.
Briefly explain what remedy, or action, you are seeking for the alleged discrimination.
Please provide any additional information and/or photographs,
if
applicable, that you believe will assist with an
investigation.
We
cannot
accept
an
unsigned
complaint.
Please
sign
and date
the
complaint
form
below.
Complainant's
Signature
Date
FOR OFFICE USE ONLY
Date Complaint Received:
Case#
:
Processed by:
Date Referred:
Referred to:
0USDOT
0FHWA
0FTA
OOFCCP
00ther
£ZA
Tom
,,.,,..,,,_,,
Forma Externa de Queja Discriminaci6n
""''""""""'
Form 2193-S
(Rev. 09/10)
Page
1
of
2
Enviar forma firmada
al
Departmento de Transporte del Estado de Texas - Oficina de Derechos Civiles,
125 East 11th Street, Austin, Texas 78701 o por fax
al
512/416-4751 .
Apellido
Nombre
Direcci6n
Ciudad Esta do C6digo Postal
Telefono Telefono Alternative
Correo Electr6nico
lndica par favor la(s) base(s) de su queja.
D Raza D Edad D Origen Nacional
D Color
D Sexo
D Discapacidad
Fecha y lugar
de
la(s) presunta(s) acci6n(es) discriminatoria(s). Favor de incluir la primera fecha de la presunta
discriminaci6n y la fecha mas reciente de la presunta discriminaci6n.
lC6mo
se discrimin6 contra usted? Describa la naturaleza de la acci6n, decision o las circunstancias de
la
presunta
discriminaci6n. Explique, de la manera mas clara posible, que sucedi6 y porque cree usted que su estatus protegido
fue
un
factor en la discriminaci6n. lncluya coma otras personas fueron tratadas de distinta manera que usted.
(Adjunte hojas adicionales de ser necesario).
La ley prohibe intimidaci6n o represalias contra cualquier persona ya sea par tomar acci6n o par participar en
la
toma
de
acci6n para asegurar las derechos protegidos par estas !eyes. Si usted siente que se han tornado
represalias en su contra, aparte
de
la
presunta discriminaci6n mencionada anteriormente, favor de explicar las
circunstancias a continuaci6n. Explique la acci6n que usted tom6 que cree sea la causa de la presunta represalia.
Nombre
de
las individuos responsables de la(s) acci6n(es) discriminatoria(s):
Form 2193-S (Rev. 09/10)
Page 2
of
2
Nombre de personas (testigos, companeros de trabajo, supervisores u otros) a quienes podamos contactar para
obtener informaci6n adicional para respaldar o aclarar
su
queja: (Adjunte hojas adicionales de ser necesario).
Nombre
Direcci6n
Telephono
1.
2.
3.
4.
lAlguna
vez ha presentado, o tiene la intenci6n de presentar, una queja con respecto a esta situaci6n
con
cualquiera de las organizaciones que se mencionan a continuaci6n? De ser asi, favor de proporcionar
las
fechas
en que se presentaron. Marque todas las que apliquen.
D Departamento de Transporte de las EE.UU.
D Administraci
6n
Federal de Carreteras de las EE.UU.
D Administraci6n de Transporte Federal de las EE.UU.
D Oficina de Programas de Cumplimiento de Contratos Federales de las EE.
UU
.
D Comisi6n para la lgualdad de Oportunidades en el Empleo de las EE.UU.
D Tribunal Federal o Estatal de las EE.UU.
D Otros
lHa
hablado sabre la queja con algun representante de TxDOT? De ser asf, favor de proporcionar el nombre y
puesto de la persona y la fecha
en
la que tuvo la conversaci6n.
Explique brevemente que remedio, o acci6n esta usted buscando par
la
presunta discriminaci6n.
Favor de proporcionar cualquier informaci6n adicional y/o fotografias,
si
son pertinentes, que usted crea ayudaran el
la investigaci6n.
No podemos aceptar una queja sin firma. Favor de incluir
su
firma y la fecha a continuaci6n:
Firma
del
Demandante
Fee
ha
UNICAMENTE PARA USO OFICIAL
Fecha de Recibo de Queja:
No. de Caso:
Procesado por:
Fecha Remitida:
Remitida a:
0USDOT
0FHWA
0FTA
OOFCCP
00ther
Attachment B - Fixed Route Maps
24
"
!
!
!
!
um
y
d
s
c nce
enter
er y - Round
ock Campus
t
o
al Center amson
tho y
4
!(
!(
!(
!(
")
")
")
")
")
")
")
")
")
")
")
")
")
")
")
")
")
")
)
")
")
")
")
^_
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(!(
!(
!(
(
(
!(
!(
!(
!(
!(!(
!(
!(
!(
!(
!(!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
(
(
!(
!(
Round Rock
Transit
Center
Allen R
Baca Senior
Center
Round Rock
Public
Library
Round Rock
City Hall
HEB
Plus!
HEB
Round Rock
Pre
mi
Outlets
LaMichoacana
Meat Market
The Salvation
Army Family
Store
Round Rock
Area Serving
Center
Texas A&M
Health S
ie
C
Texas State
U
niv sit
R
Emerson
Howard
Station
Stony Poin
High Scho
Baylor Scott
& White
Hospital
Seton Medic
LaFrontera
Housing
Authority
Housing Au rit
Success
High
School
BluebonnetTrails
The Art
Institute
of Austin
Austin Communit
C
ollege - Roun
Rock Campu
l
Sources: Esri, DeLorme, NAVTEQ, USGS, NRCAN, METI, i
Round Rock - Howard Station, Route 50
Transit Stops
"
Points of Interes
)
t
Park & Ride
^_
!
Proposed
(
Transit Route
Round Rock-Howard Station,50 (proposed)
CapMetro 243 (existing)
CapMetro Red Line (Light Rail), 50
Willi
PC, TomTom
!(
AVTE USGS NRCAN METI iPC TomTo
"
"
"
"
"
"
"
"
"
"
^
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
!(
Round Rock
Transit
Center
Allen R Baca
Senior Center
Round Rock
City Hall
LaMichoacana
Meat Market
Round Rock
High School
Housing
Authority
Housing
Authority
Success
High School
C
Rec
Round Rock
Public Library
Dell
Round Rock Circulator, Route 51
"
"
"
"
"
_
!(
!(
!(
!(
HEB
HEB
Walmart
Target
St.David's Round
Rock Hospital
lay Madsen
reation Center
Sources: Esri, DeLorme, N Q, , , , , m
Transit Route
Round Rock Circulator, 51 (proposed)
Stops
"
Points of Interest
^
Park & Ride
_
!
Stops Proposed
(
Attachment C - ADA Paratransit Service Application
27
ADA Paratransit Eligibility Application
Round Rock Paratransit Service is for individuals with a disability which prevents them from independently traveling on
the fixed route service either all of the time or some ofthe time. The Americans with Disabilities Act (ADA) outlines
specific criteria to determine eligibility for paratransit services; therefore, an application and an in-person eligibility
review are required to determine an applicant’s individual eligibility.
If you need any type of alternative format of this application or have any questions please contact (512) 218-7074.
To apply for this service, you and your healthcare professional must complete this application. Other supportive
documentation may be included with your application. The information you provide may be shared with other transit providers to
facilitate your travel in other areas.
Please read and follow these instructions.
1
You complete Part A: Applicant Information & Release
Your healthcare professional completes
Part B: Healthcare Provider Verification
. The applicant MAY
NOT complete this section.
A healthcare professional authorized to complete
Part B: Healthcare Provider
Verification
include, doctors of medicine, doctors of osteopathic medicine, doctors of chiropractic,
registered nurses, physician assistants, nurse practitioners, certified nurse specialist, certified registered
nurse anesthetists, clinical social worker, and physical, speech, occupational, and massage therapists.
2
Once ALL paperwork is complete, you may either:
o Mail to or deliver in person to: City of Round Rock, ATTN: Transit Coordinator, 2008 Enterprise Drive,
Round Rock, Texas 78664
o Fax to: (512) 218-5536
o Email to: clee@roundrocktexas.gov
ORIGINALS ARE REQUIRED TO BE SUBMITTED – if your original completed application is not mailed, then
you MUST bring the originals with you to the in-person interview
3
All information received in this application will be kept CONFIDENTIAL
4
You will receive your eligibility determination within 21 calendar days from the date ALL of the following are
completed:
o Original full application and verification received
o In-person interview
o Any additional requested information is received by staff
o Any applicant who has completed the above steps but has not received an eligibility determination
letter, within 21 days, will be entitled to unlimited use of the paratransit service until you are
notified your eligibility determination.
ADA Paratransit Eligibility Application
PART A: APPLICANT INFORMATION & RELEASE (please print)
Step 1: General Information
Last Name First Name MI
Street Address Apt # Gate Code
City/State/Zip
Gender ☐Male ☐Female Date of Birth
Email
Primary Phone Number ☐Home ☐Cell ☐Work
Secondary Phone Number ☐Home ☐Cell ☐Work
Emergency Contact Name Relationship
Emergency Contact Phone ☐Home ☐Cell ☐Work
Step 2: Disability Information
1. What disability have you been diagnosed with?
2. Does your disability prevent you from using the fixed route bus service? ☐Yes ☐No If yes, please explain:
3. Is your disability considered permanent? ☐Yes ☐No If no, how long do you expect to have this disability:
4. Does your disability change from day-to-day or seasonally? ☐Yes ☐No If yes, please explain:
ADA Paratransit Eligibility Application
Step 3: Mobility Information
1. What is the closest bus stop to your home?
2. Do you used the fixed route bus service now? ☐Yes ☐No ☐Sometimes If no or sometimes, please explain:
3. Are you able to travel to the bus stop by yourself? ☐Yes ☐No ☐Sometimes If no or sometimes, please explain:
4. Are you able to board the bus by yourself, with or without the use of the accessible ramp?
☐Yes ☐No ☐Sometimes If no or sometimes, please explain:
5. Do you need someone to accompany you when you travel outside the home, i.e. personal care attendant, someone
designated or employed to specifically help with personal needs? ☐Yes ☐No If yes, please explain:
6. Does weather affect your ability to use the fixed route bus service? ☐Yes ☐No If yes, please explain:
7. Do you use any of the following mobility aids or specialized equipment? ☐Yes ☐No If yes, please select all that
apply:
☐Wheelchair, Type ☐Walker, Type
☐Scooter ☐Crutch(es) ☐Brace(s) ☐Support Cane
☐White Cane ☐Service Animal ☐Oxygen ☐Prosthesis
☐Communication Board ☐Other
ADA Paratransit Eligibility Application
8. Have you ever received any travel training? ☐Yes ☐No If yes, who provided the training:
Step 4: Applicant Certification
I certify all information contained in PART A of this application was completed by me or my authorized representative
and is true and correct. I agree to notify the City of Round Rock of any changes in my status, which may affect my
eligibility to use the service. I understand I will be required to attend an in-person eligibility review.
I have read and fully understand the conditions for service outlined in the ADA Complementary Paratransit Plan and
agree to abide by them. I also understand failure to adhere to the policies and procedures will be grounds for revoking
my application and the right to participate in the program.
I agree that, if I am certified for Round Rock Paratransit Service, I will pay the exact fare, if required, for each trip.
I understand and agree to hold the City of Round Rock harmless against all claims or liability for damages to any person,
property, or personal injury occurring as a result of my failure to equip or maintain the safety of the adaptive equipment
or service animal I require for mobility.
I hereby authorize the release of verification information and any additional information to the City of Round Rock for
the purpose of evaluating my eligibility to participate in the Program.
Signature Date
Authorized Representative Information
Name Phone Number
Relationship to the Applicant
Signature Date
This concludes the !pplicant’s portion of the application.
The following pages MUST be completed by a Qualified Healthcare
Professional.
DO NOT SEPARATE - All parts of this application must be kept
together and submitted together.
ADA Paratransit Eligibility Application
PART B: HEALTHCARE PROVIDER VERIFICATION (please print)
Step 1: Purpose of this Verification
Dear Provider:
Your patient/client has requested eligibility for Round Rock Paratransit Service. To qualify for Round Rock Paratransit
Service, the applicant’s disability must prevent them from travelling independently on Round Rock Transit’s fixed route
service, either all of the time or some of the time. Disability alone and distance to and from a bus stop do not, by
themselves, qualify a person for paratransit service. For the benefit of the applicant, please answer all applicable
questions as fully and accurately as possible. All information will be kept strictly confidential, according to law.
If you have any questions about the verification please contact the Transit Coordinator at (512) 218-7074.
Step 2: Applicant Information
Applicant Name Date Last Seen
1. Please describe the medical diagnosis, physical or cognitive disability
2. Please describe how the disability impacts the applicants use of fixed route service
3. Is the disability permanent? ☐Yes ☐No If no, what is the expected duration?
4. Is a personal care attendant required? ☐Yes ☐No
5. Does weather affect the applicant’s ability to travel? ☐Yes ☐No If yes, please explain:
ADA Paratransit Eligibility Application
6. Does the applicant have the ability to:
Give addresses and phone numbers?
Recognize a destination or landmark?
Deal with an unexpected change in routine?
Ask for, understand and follow directions?
Step 3: Certification
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
Last Name First Name MI
Phone Number Fax Number
Title License/Certification ID #
Agency Affiliation
Street Address
City/State/Zip
I certify the information contained in Part B is true and correct to the best of my knowledge. I hereby verify the
diagnosis of disability listed has been reviewed by me, is accurate and true, and represents the current condition of the
applicant named in this application.
Signature Date
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

ROUND ROCK TEXAS TRANSIT (City of Round Rock, Texas)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document