AMERICANS WITH DISABILITY ACT (ADA) COMPLEMENTARY PARATRANSIT ELIGIBILITY APPLICATION

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1 AMERICANS WITH DISABILITY ACT (ADA) COMPLEMENTARY PARATRANSIT ELIGIBILITY APPLICATION The attached application must be completed by individuals who wish to apply for eligibility in the ADA Paratransit program. To Apply for ADA Eligibility: 1. Applicants fill out pages 2-7 COMPLETELY. A medical professional or social worker must complete page The application is then mailed to: PARTA-ADA Eligibility 2000 Summit Road Kent, Ohio You will be notified of your ADA eligibility status within 21 working days of the date that we receive your completed application. All applications that are not entirely and correctly completed will be returned to the applicant and not processed. 1

2 PORTAGE AREA REGIONAL TRANSPORTATION AUTHORITY Application for Paratransit Service If your disability/medical condition or system accessibility/environmental barriers, prevents you from riding Fixed Route buses, you may be eligible for Paratransit Service some or all of the time. If your disability just makes riding Fixed Route more difficult or inconvenient, you may not be eligible for Paratransit Service under the Americans with Disabilities Act (ADA). Your ability to ride Fixed Route buses will be evaluated through the use of this application. The more information you provide, the better PARTA will understand your ability and travel challenges. Please complete this application as thoroughly as possible and to the best of your ability. If there are questions that you cannot answer, or if you need assistance to complete this form, please call the Scheduling Department at (330) In order to be considered complete, every question on the application must be answered. If not, it will be returned to you for completion. Your licensed physician or health care professional must complete part VII of this application, the Medical Professional Certification. Please use blue or black ink. PART I: Background Information of Applicant Name: Last First M.I. Address: City: State: Zip: Phone: (Home): (Work): Date of Birth: Sex: Male Female Emergency Contact Person: Phone: (Home): (Work): Relationship to Applicant: Date entered in system Form Reviewed on date Category Disablility Code Eligibility Approved Yes No Date OFFICE USE ONLY rev. 12/06 2

3 PART II: Information About Your Disability 1. Does your health condition/disability require you to use Paratransit Service: Seasonally (Nov.-Apr.) Permanently Temporarily If temporarily, for how long? Week(s) Month(s) Year(s) 2. Please indicate the primary mobility aid you use when traveling in the community: Support Cane Leg Braces Picture Board Red Tip White Cane Crutches Alphabet Board Service Animal Walker Powered Wheelchair Hearing Aid Prosthesis Manual Wheelchair Oxygen Tank Hearing Device Scooter Other Note: PARTA s equipment is designed to transport mobility aids that fit the ADA definition of the common wheelchair of 48 long and 30 wide with a combined weight of 600 pounds while occupied. 3. Can you climb three steps with a handrail, without assistance? Yes No Sometimes 4. Do you use a Personal Care Attendant (PCA) to help you travel? A PCA is a person specifically employed or designated to help with your daily living needs. Yes No Sometimes 5. Have you used or been trained to use PARTA Fixed Route buses? Yes No 6. Check the items listed below that might help you ride PARTA Fixed Route buses: Help with trip planning Bus stops closer to my house Help with communicating Accessible route to bus stop Someone to teach me 7. Does your health condition/disability change from day to day in a way that occasionally disrupts your ability to use regular route bus service? Yes No If yes, please explain why: 3

4 Please check which condition(s) prevents you from accessing the PARTA Fixed Route bus system: None Distance to the bus stop How far is the nearest bus stop? Disability prevents the use or access of PARTA Fixed Route bus service. Which of the following condition(s), if any, prevent you from using the Fixed Route system? Check all that apply: None Physical Brain Injury Deaf / Hard of Hearing Visual Mental Illness Developmental Disability Other Briefly explain why this prevents you from using Fixed Route buses. 4

5 PART III: Applicant Certification I understand that the purpose of this application is to determine if I am eligible for PARTA s Paratransit services and that PARTA staff may need to talk to me later to get more information. By signing this application, I certify that I have been truthful in answering this form and that the information that I have provided is correct to the best of my knowledge. I understand that falsification of this information could result in a loss of Paratransit service. I agree to notify PARTA if I no longer need to use the Paratransit service. Signature Date PART IV: To be completed ONLY if another person helped the applicant in the completion of this form Name of Person Giving Assistance: Address: City: State: Zip: Phone: (Home): (Work): Relationship to Applicant: PART V: Applicant Authorization for release of medical information I authorize the professional(s) listed below to release to PARTA information about my disability and health condition and its effect on my ability to travel on PARTA buses. I understand that I may revoke this authorization at any time. All medical information, which you or your health care professional provide, will be kept confidential to the extent permitted under the law except that the information may be shared with other professionals or agencies involved in the determination of your eligibility. Signature Date 5

6 PART VI: Medical professional certification to be completed by your licensed physician or health care professional. PLEASE PRINT. Name: Office Address: City: State: Zip: Office Telephone Number: License/ Certification No.: State: A licensed professional who is knowledgeable about the applicant s disability and their limitations must fill out this form. Please check the appropriate box regarding the person completing this form. Vocational Rehabilitation Counselor O & M Instructor Licensed Social Worker Physician Respiratory Therapist Physical Therapist Psychologist Mental Health Counselor Psychiatrist Podiatrist Audiologist Optometrist Independent Living Specialist Other Professional must initial each statement to which you agree. I certify that I have treated the Applicant and am familiar with his/ her disability and health condition. I certify that I have read and agree with the Applicant s information in its entirety. I certify that the Applicant is UNABLE to ride PARTA s fixed route bus services. I certify that the Applicant is capable of being transported by PARTA s equipment. (PARTA s paratransit vehicles are capable of lifting the required 600 lbs.) Why is applicant unable to use fixed route service. Please explain: If condition is not permanent, please indicate duration I understand that false certification may be reported to the licensing jurisdiction under the State of Ohio or appropriate code for state of license/ certification. Signature Date 6

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