Applicatio For Scat Bus Form – Fill Out and Use This PDF

Suffolk County Office of Handicapped Services

North County Complex, Bldg. 158

Veterans Memorial Highway

P.O. Box 6100

Hauppauge, NY 11788-0099

COUNTYOFSUFFOLK

STEVE LEVY

SUFFOLK COUNTYEXECUTIVE

OFFICE OFTHE COUNTYEXECUTIVE	OFFICE OFHANDICAPPED SERVICES
	BRUCE G. BLOWER
	DIRECTOR

Dear ParatransitApplicant:

Enclosed is an application for the Suffolk CountyAccessible Transit (SCAT) Paratransit system. SCATis for people whose disability is so severe that it prevents them from using public buses. It is not necessary for you to obtain a medical certification, but please answerall the questions. This will enable us to determine your eligibility.All information will be kept confidential.

When you have completed and signed the application, mail it and two identical (orsimilar) black and white, orcolorpassport size photographs (no photocopies) to:

Suffolk County Office of Handicapped Services

Building 158, North County Complex

P.O. Box 6100

Hauppauge, NY 11788-0099

You will be notified as to your eligibility by mail within three weeks.

The specifications for the two original photographs are: clear, full face, front view. Your face should fit in a 1˝ x 1 1⁄4˝ area, the size of the box below, just print your name on the back of each photo and attach them to the application.

On the other side of this cover letter is information about Paratransit. If you have any questions, or need assistance filling out the application, please feel free to call us at 853-8337 (voice), or if hearing impaired phone 853-5658 (TTY).Also, copies of the federal Department of Transportation andADAParatransit standards are available upon request.

SCAT-PARATRANSIT PROCEDURES AND GUIDELINES

1.To make a trip reservation, call the Suffolk County Accessible Transit (SCAT) Paratransit dispatcher at 631.738.1150 (voice) or 631.981.0104 (TTY). ALL RESERVATIONS ARE SUBJECT TO AVAILABILITY. Riders are entitled to trips on a first-come, first-served basis.

2.Reservations may be made up to 7 days in advance and no later than one day prior to the day you want to ride, if available. Multiple reservations can be made at one time. Since reservations are on a first-come, first-served basis you may not always get the reservations you desire if those time slots have already been taken.

3.Reservations can be made between 8:00 am and 4:30 pm, Monday through Saturday. On Sundays, reservations can be made between 8:00 am and 4:30 pm, for next day travel only.

4.The first daily pick-ups begin as early as 6:00 am on Monday through Friday, (7:00 am on Saturday), and the last daily pick-up will be at about 8:30 pm and later in those areas where SCT bus lines continue to operate later in the evening. Please note that since there is no bus service on Sundays or on holidays there is no Paratransit service on these days either.

5.The fare is $3.00 one way ($6.00 round trip). Exact fare is required.

6.For riders requiring a personal care attendant (PCA), as shown on ID card, the attendant will travel free. In addition to the PCA, one companion can also accompany the rider by paying the full fare. Additional companions may also accompany the rider, but only if sufficient vehicle capacity can accommodate them and they each must also pay the full fare.

7.Riders must have their I.D. card with them when using SCAT identifying them as ADA Paratransit eligible. (If you do not yet have your ID card, bring your eligibility certification letter along on the trip).

8.If cancellation of your reservation is necessary, it must be made at least two (2) hours before your scheduled pick-up time. In an emergency, call as soon as possible. However, riders who are repeat no shows or cancel excessively risk having their riding privileges suspended or revoked.

9.Service is curb-to-curb only. Please do not ask driver for door-to-door service. You must be at the curb

15 minutes before your scheduled pick up. Drivers cannot leave the bus to bring riders to or from the curb.

10.All pick-up and drop-off locations must be within Suffolk County, NY. Trip origins and destinations must be within 3/4 of a mile of a Suffolk County Transit or HART (for trips within Huntington) fixed bus route.

11.Please note the SCAT bus has a half-hour window, where they can show up 15 minutes before or 15 minutes after your scheduled pick-up time. YOU MUST BE READY DURING THIS ENTIRE WINDOW BECAUSE THE BUS WILL NOT WAIT MORE THAN 10 MINUTES FOR YOU.

12.If you are able to use the public bus system for any trips, we urge you to do so, to make room for people who can only travel via Paratransit. Thank you for your cooperation.

PLEASE RETAIN THIS COPY FOR YOUR RECORDS

SCAT PARATRANSIT APPLICATION FORM

PART 1. GENERAL INFORMATION

M F

CITY:

COUNTY:

ZIP CODE:

HOME PHONE

WORK PHONE

NUMBER (

) ______ - __________

NUMBER (

) ______ - __________

NEAREST CROSS STREET

EMAIL: _______________________________________

MAILING ADDRESS: If different from above

STREET ADDRESS:

APT/BLDG #:

CITY:

COUNTY:

ZIP CODE:

1. Do you require information and material given to you in any of the following ways?

Mark all that you need

■ Braille

■ Large Print

■ Audio Tape

■ Other: ________________________

PLEASE GIVE US THE NAME AND TELEPHONE NUMBER OF SOMEONE WE CAN CALL IN AN EMERGENCY.

LAST NAMEFIRST NAME

HOME PHONE				WORK PHONE
NUMBER (		) ______ - __________		NUMBER (		) ______ - __________
			DO NOT WRITE BELOW THIS LINE
			CERTIFICATION DATA
ID# _________________________							DATE RECEIVED

Date Issued:_______________________________

Expiration Date: ____________________________

Eligibility Category: _________________________

Certifier: __________________________________

Comments:________________________________

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SCAT PARATRANSIT APPLICATION FORM

2. Please indicate below if you use any of the following mobility aides or equipment.

● Cane	● Manual wheelchair
● Crutches	● Powered wheelchair
● Long white cane (for the visually impaired)	● Powered scooter/cart
● Service/guide animal (describe) _______________	● Respirator/oxygen tank
● Walker	● Other _____________________
● Leg braces	● I don’t require any assistive devices

Note: We may not be able to accommodate the applicant if the wheelchair or scooter is longer than 48” or wider than 32 3/4”, or if the combined weight of the applicant and wheelchair is more than 600 pounds.

PART 2. QUESTIONS ABOUT USING FIXED BUSES

3.Have you ever used the fixed route buses?

●Yes, I typically use fixed route buses ___________ times a week.

●Yes, but only for trips I am familiar with.

●Yes, I used to but stopped because _________________________________________

●No

4.If you currently do not use the fixed route is there something that might help you to ride the buses? (Mark all that apply.)

●	Yes, route and schedule information.	●	Yes, buses with wheelchair lifts.
●	Yes, learning to use the buses.	●	Yes, a communication aid.

●Yes, if bus stops were closer to where I live and where I need to go.

●Yes, (describe): _______________________________________

●No, none of these would help.

5.How far from your home is the nearest bus stop?

●	Less than 1 block	●	5 or more blocks
●	1-2 blocks	●	I don’t know

●3-4 blocks

6.On your own or using an assistive device, how far can you travel?

●I can get to the curb in front of my house/apartment

●I can travel up to 3 blocks (1/4 mile)

●I can travel up to 6 blocks (1/2 mile)

●I can travel up to 9 blocks (3/4 mile)

●I don’t know.

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SCAT PARATRANSIT APPLICATION FORM

7.Please mark ALL the disabilities that prevent you the applicant from using the fixed route.

	■ AIDS	■ Kidney Disease/Dialysis
	■ Alzheimer’s Disease	■ Legally Blind
	■ Asthma	■ Lupus
	■ Arteriosclerosis	■ Macular Degeneration
	■ Arthritis	■ Mental Retardation
	■ Autism	■ Multiple Sclerosis
	■ Cancer	■ Muscular Dystrophy
	■ Cataracts	■ Other: ___________________
	■ Cerebral Palsy	■ Panic Disorder
	■ Congestive Heart Failure	■ Paraplegia
	■ COPD	■ Parkinson’s Disease
	■ Cortical Blindness	■ Peripheral Vascular Disease
	■ Cystic Fibrosis	■ Phobia
	■ Dementia	■ Quadriplegic
	■ Diabetes (severe)	■ Retinopathy
	■ Emphysema	■ Schizophrenia
	■ Epilepsy (severe)	■ Spina Bifida
	■ Heart Attack	■ Stroke/Cerebral Trauma
	■ Head Trauma	■ Thrombosis (chronic)
		■ Totally Blind

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SCAT PARATRANSIT APPLICATION FORM

8.How does your identified disability prevent you, the applicant from riding the fixed route buses? Please explain in DETAIL.

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

9.Is this condition permanent? YES NO Is this condition temporary? YES NO

If temporary, what is the expected duration? _____________________

(Number of months)

10.Does the applicant need to travel with their own Personal Care Attendant (PCA)?

■Yes

■No

■Sometimes

11.Is the applicant able to travel to and from a bus stop?

Yes No

If no, please indicate all that apply:

■Cannot negotiate where there are no sidewalks.

■Cannot travel if there are no curb cuts.

■Cannot cross busy streets and intersections.

■Cannot tolerate extreme temperatures.

■Cannot travel on surfaces covered with ice/snow.

■Cannot locate or identify bus stop due to a visual impairment.

■Easily becomes confused and may get lost.

■Other (please specify): __________________________________

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SCAT PARATRANSIT APPLICATION FORM

12.Is the applicant able to perform the following functions without assistance from another person?

		YES	NO
	Find his/her way between familiar locations?	■	■
	Grasp coins, passes, railings, and handles?	■	■
	Climb up and down three 12 inch steps?	■	■
	Travel 3/4 mile to a bus stop?	■	■
	Identify the stop at your destination?	■	■
	Deal with unexpected situations or unexpected	■	■
	changes in routine?

Please list the names of two professionals, (physicians, agencies, or others familiar with your disability), whom we may contact if verification of information is required:

Phone
Name: ___________________________________ Number: (		) ______-__________

Address: __________________________________________________________________

__________________________________________________________________

Address: __________________________________________________________________

__________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

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SCAT PARATRANSIT APPLICATION FORM

Release and Certification of Information:

I, the applicant, understand that the purpose of this application form is to determine my eligibility to

use the SCAT System. I agree to release the information requested to SCAT and any eligibility review panel and understand that the information contained herein will be treated confidentially. I understand that SCAT reserves the right to request additional information at its discretion.

I hereby certify that ALL information provided by me on this application is TRUE and ACCURATE.

ANY FALSE STATEMENTS MADE HEREIN ARE PUNISHABLE

PURSUANT TO PENAL LAW 210.45 OF THE STATE OF NEW YORK.

________________________________________________________________________________

Signature of applicantDate

________________________________________________________________________________

Printed name of applicant

________________________________________________________________________________

Signature of preparer (if other than applicant)Date

________________________________________________________________________________

Printed name of preparer, relationship or agency name

________________________________________________________________________________

This application form must be completed and sent, together with 1” x 1 1/4” identification-type photos as described in the cover letter to:

SCAT

c/o Suffolk County Office of Handicapped Services Bldg. 158, North County Complex

P.O. Box 6100

Hauppauge, NY 11788-0099

(631)853-8333 (VOICE)

(631)853-5658 (TTY)

13-0130p. 09/05kd

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