Tri Delta Transit ADA Paratransit Application Packet.
[Pages:15]Tri Delta Transit ADA Paratransit Application Packet.
This packet contains the following:
1) Information/instructions for completing your application (pages 2-3)
2) ADA Paratransit Application (pages 3 ? 12)
3) Medical Verification Form to be completed by your medical professional (pages 13 ? 15)
1
Tri Delta Transit Application for ADA Paratransit Service
Revised: 07/2018
Important Application Information for ADA Paratransit Transportation
ADA Paratransit Transportation Eligibility Eligibility is determined on a case-by-case basis in accordance with the Americans with Disabilities Act (ADA). Disabled status is strictly limited to those who have limitations that prevent them from using accessible fixed route transportation. If you are found to be capable of using fixed route bus service, you will not be eligible for ADA Paratransit transportation.
To apply for eligibility, you must fully complete and return the attached application and Medical Verification Form. We will review your ability to use accessible fixed route transportation. After reviewing your application and the information provided by your health care professional, we may need to contact you by phone or schedule a personal interview or a functional evaluation. The functional evaluation will help us determine your ability to take a public transit trip.
Once your fully completed application and medical verification form is received your application will be processed within 21 days. You will receive notice of your eligibility determination by mail.
If you are certified as ADA eligible, you can travel on Tri Delta Transit's ADA Paratransit transportation system as well as on paratransit systems throughout the nine-county Bay Area. If you are found to be ineligible and do not agree with the eligibility determination, you have the right to appeal. Information on how to file an appeal will be included with your eligibility determination letter if your ADA status is denied.
2
Tri Delta Transit Application for ADA Paratransit Service
Revised: 07/2018
Instructions to Apply for ADA Paratransit Transportation
1. Complete the entire application: Please PRINT OR TYPE full responses to all questions on the application form. If any questions are not answered, your application will be considered incomplete. Incomplete applications will be returned.
2. Sign the following two pages: 1) PAGE 10: Applicant Certification 2) PAGE 12: Medical Release Form
3. Have your physician or medical professional complete the Medical Verification form, pages 13 - 15
4. If you require a personal care attendant, complete and sign the form entitled Certification for Personal Care Attendant (page 9).
5. Fax or mail your completed application and medical verification form in the enclosed addressed envelope.
Tri Delta Transit Paratransit 801 Wilbur Ave Antioch, CA 94509 Fax: 925-757-2530
? For help with the application process call (925) 754-6622 ? All information that you supply on your application will be kept strictly
confidential.
3
Tri Delta Transit Application for ADA Paratransit Service
Revised: 07/2018
ADA Paratransit Application
(Please Print or Type)
Name (first, middle, last): _____________________________________________________________
Home Address: ________________________________ Apt. #: _________
City: _______________________________________________ Zip: ______
Mailing Address (if different from home): ______________________________________________ Apt. #: _________
City: ___________________________________________ Zip: __________
Cell Phone: (_____) _________________ TDD/TTY: (____) ___________
Home Phone: (_____) _______________
Birth Date: ____/____/____ c Female c Male
Primary Language (please check): c English
c Other (specify)______
If you need any future written information provided to you in an accessible format, please check which format you prefer:
c Diskette/CDR c Audio tape c Braille c Large Print c Other
In case of emergency, whom should we contact?
Name: ___________________________ Relationship: _________________
Cell Phone: (____) _____________Home. Phone: (____) _____________
If there is a medical emergency, where do you want to be transported?
Hospital: _______________________________ City: __________________
4
Tri Delta Transit Application for ADA Paratransit Service
Revised: 07/2018
Tell Us About Your Disability / Health Related Condition
Please answer the following questions in detail ? your specific answers to the questions will help us in determining your eligibility.
1. What is your Disability or Health Related Condition(s) that PREVENT you from using regular public transit without the help of another person (i.e. bus, BART, streetcar)? _________________________________________________________ _________________________________________________________ _________________________________________________________
2. Briefly explain HOW your condition prevents you from using regular public transit without the help of another person. _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________
3. When did you first experience the conditions you described above?
0-1 year ago 1 ? 5 years ago
Longer than 5 years
4. Do the conditions you described change from day to day in a way that affects your ability to use public transit? c Yes, good on some days, bad on others. c No, doesn't change.
5. Are the conditions you described:
c Permanent
c Temporary
If temporary, how long do you expect this to continue? _________________________________________________________
5
Tri Delta Transit Application for ADA Paratransit Service
Revised: 07/2018
Tell Us About Your Capabilities and Usual Activities
6. Do you use any of the following mobility aids or specialized equipment?
(Check all that apply):
c Cane
c Power Wheelchair c Communication Devices
c White Cane c Service Animal
c Walker
c Power Scooter c Crutches
c Manual Wheelchair
c Leg Braces c Portable Oxygen Tank
c Other Aid ______________________________________________
7. How many city blocks can you travel with your usual mobility aid and without the help of another person? __________________________
8. Please check the box that best describes your current living situation: 24-hour care or Skilled Nursing Facility Assisted Living Facility I receive assistance from someone that comes to my home to help with daily living activities I live with family members who help me I live independently (without the assistance of another person)
9. Which of the following statements best describes you if you had to wait outside for a ride? (Check only one response):
c I could wait by myself for ten to fifteen minutes c I could wait by myself for ten to fifteen minutes only if I had a
seat and shelter c I would need someone to wait with me because:________________ _________________________________________________________
10. Which of the following statements best describes you? (Check only one response): c I have never used regular public transit c I have used regular public transit but not since the onset of my disability c I have used regular public transit within the last six months
6
Tri Delta Transit Application for ADA Paratransit Service
Revised: 07/2018
Tell Us About Your Travel Needs
11. How do you currently travel to your frequent destinations?
(Check all that apply):
c Buses c Paratransit c Drive myself c BART
c Taxi c Ferry
c Streetcar c Someone drives me
c Other__________________________________________________
12 . Do you travel with the help of another person?
c Always c Sometimes
c Never
If always or sometimes, what type of help do they provide? _________________________________________________________ _________________________________________________________
13. Would you be able to get to and from the public transit stop nearest your
home?
c Yes c No
c Sometimes
If no or sometimes, explain why:________________________________ __________________________________________________________
14. Would you be able to grasp handles or railings, coins or tickets while
boarding or exiting a transit vehicle?
c Yes c No
c Sometimes c Don't know, never tried it
If no or sometimes, explain why: _________________________________________________________ _________________________________________________________
15. Would you be able to maintain balance and tolerate movement of a public
transit vehicle when seated?
c Yes c No
c Sometimes c Don't know, never tried it
If no or sometimes, explain why: _________________________________________________________ _________________________________________________________
7
Tri Delta Transit Application for ADA Paratransit Service
Revised: 07/2018
16. Would you be able to get on or off a public transit bus if it has a lift, a
ramp, or a kneeler that lowers the front of the bus?
c Yes c No
c Sometimes c Don't know, never tried it
If no or sometimes, explain why:
_________________________________________________________
_________________________________________________________
17. Please add any other information that you would like us to know about your abilities.
_________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________
Have you answered all the questions and provided explanations where required? INCOMPLETE APPLICATIONS WILL BE RETURNED.
8
Tri Delta Transit Application for ADA Paratransit Service
Revised: 07/2018
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- medical health form golden empire transit
- ada paratransit eligibility certification form
- not for use for hospital discharges transfers baltimore
- 13 0130 for transportation sct bus
- plus application and medical information release
- medical transportation ground billing codes and
- eligibility application
- medical eligibility application regional transit
- attendant transportation service application
- special transportation services sts application form
Related searches
- dod tri annual review guidance
- ada city utilities ada ok
- tri fuel generators 12000 watt
- honda tri fuel generators
- honda tri fuel inverter generator
- city of ada utilities ada ok
- ada water department ada ok
- dod tri annual review checklist
- ada utilities ada ok
- free tri fold brochure maker
- ada family dentistry ada ok
- ada family dentistry ada ohio