HandiVan Application
(To be completed by applicant)
GENERAL INFORMATION
Name:___________________________________________________________________
Address:_________________________________________Phone:___________________
City/State/Zip:_____________________________________________________________
Birthdate:__________________________Social Security #:_________________________
Emergency Contact Name:____________________________________________________
Phone:____________________________Relationship:_____________________________
APPLICANT’S CERTIFICATION:
Please indicate the reasons why you are seeking ADA paratransit eligibility (check all that apply):
_____I can use accessible, fixed-route city buses to go some places but in certain
circumstances I cannot use accessible, fixed-route city buses.
_____Because of my disability I can never use the accessible, fixed-route city buses.
I understand that the purpose of this evaluation form is to determine if there are times when I cannot use the accessible, fixed-route city bus service provided by StarTran and must therefore use the HandiVan service. I understand that the information about my disability contained in this application will be kept confidential and shared only with professionals involved in evaluating my eligibility. I certify that, to the best of my knowledge, the information in this evaluation form is true and correct. I understand that providing false or misleading information could result in my eligibility status being reviewed as well as other possible actions by StarTran.
Applicant’s signature:_________________________________________________________
Date:________________________________
1.What type or types of disabilities prevent you from using the accessible, fixed-route city bus service? (Check all that apply).
General Medical Condition
_____None
_____Cancer Treatment
_____Diabetes
_____Dialysis
_____Other (describe)_________________________________________________
Bone and Joint Condition
_____None
_____Arthritis
_____Osteoporosis
_____Amputation of___________________________________________________
_____Broken bones (specify)____________________________________________
_____Other (describe)__________________________________________________
Brain/Nerves/Muscle Condition
_____None
_____Alzheimer’s Disease
_____Brain Injury
_____Cerebral Palsy
_____Confusion
_____Dementia
_____Epilepsy
_____Multiple Sclerosis
_____Paraplegia
_____Parkinson’s Disease
_____Post-polio
_____Quadriplegia
_____Stroke
_____Other (describe)___________________________________________________
Heart and Circulatory Condition
_____None
_____Edema
_____Heart Disease
_____Other (describe)__________________________________________________
Lung and Breathing Condition
_____None
_____Asthma
_____Chronic Obstructive Pulmonary Disease
_____Emphysema
_____Lung Cancer
_____Other (describe)___________________________________________________
Vision/Hearing/Speech Condition
_____None
_____Deaf
_____Deaf-Blind
_____Diabetic Retinopathy
_____Glaucoma
_____Hard of Hearing
_____Legally Blind
_____Night Blindness
_____Non-Verbal
_____Other (describe)_________________________________________________
Developmental or Mental Condition
_____None
_____Developmental Disability
_____Mild
_____Moderate
_____Severe
_____Mental Retardation
_____Mild
_____Moderate
_____Severe
_____Autism
_____Downs Syndrome
_____Mood Disorder
_____Psychosis
_____Other (describe)__________________________________________________
Please describe your medical condition/disability in more detail:_______________________
__________________________________________________________________________
2.Is the medical condition/disability temporary or permanent?
_____permanent
_____temporary; I expect it to last __________
_____I don’t know
3.Does your health condition/disability change from time to time in ways which affect your ability to use an accessible, fixed-route city bus?
_____no
_____yes (describe)____________________________________________________
4.Please indicate if you use any of the following mobility aids or equipment. (Check all that apply.)
_____cane
_____crutches
_____leg braces
_____walker
_____alphabet/picture board
_____portable oxygen
_____power scooter/cart
_____power wheelchair
_____manual wheelchair
_____service animal
_____other (describe)__________________________________________________
5.Do you require the assistance of a Personal Care Attendant (PCA) (someone who assists you with daily life functions) when traveling within the City?
_____no
_____yes
6.Have you ever used the accessible, fixed-route city bus service?
_____yes, I use the accessible, fixed-route city bus service
about _____ times a week
_____yes, I did in the past but have stopped because__________________________
_____no
7.Is there something that might help you to ride the accessible, fixed-route city buses? (Check all that apply.)
_____yes, route and schedule information
_____yes, learning to use the accessible buses
_____yes, a communication aid
_____yes, if bus stops were closer to where I live or to where I need to go
_____yes (describe)___________________________________________________
_____no, none of these would help
8.Can you ask for and follow written or oral instructions to use the accessible, fixed-route city buses?
_____yes
_____no
_____sometimes
_____I don’t know because I have never tried to use the accessible bus service
If no or sometimes, please check all that apply.
_____I get too confused and might get lost
_____Other people cannot understand me
_____I probably could with instruction
_____other (describe)_____________________________________________________
9.Are you able to get to and from bus stops on your own?
_____yes
_____no
_____sometimes
_____I don’t know because I have never tried
If no or sometimes, please check all that apply.
_____I can’t get places if there are no curb cuts
_____I can’t if the street or sidewalk is too steep
_____I cannot cross busy streets or intersections
_____I cannot travel outside when it is too hot
_____I cannot travel outside when it is too cold
_____I can’t find my way at night because of vision problem
_____I get confused and cannot find my way
_____I probably could with instruction
_____other (describe)__________________________________________________
10.Using a mobility aid or on your own, how far can you travel?
_____I cannot travel outside my house or apartment
_____I can get to the curb cut in front of my house/apartment
_____I can travel up to four blocks
_____I can travel more than four blocks
11.Can you wait for an accessible, fixed-route city bus at a bus stop?
_____no (explain)_____________________________________________________
_____yes, but only if the stop has a bench and/or shelter
_____yes, but only up to _____ minutes
12.Can you get on and off an accessible, fixed-route city bus? (Note: StarTran fixed-route buses now have wheelchair lifts and a “kneeler” which lowers the height of the steps. Passengers who find the steps to be too high may enter and exit the bus by standing on the lift.)
_____yes
_____no
_____sometimes
_____I don’t know because I have never tried
If no or sometimes, please check all that apply.
_____I don’t want to use the lift (explain)__________________________________
_____I probably could with instruction
_____other (describe)__________________________________________________
13.If you are able to get on and off an accessible, fixed-route city bus, do you know where to get off the bus or can you find out by yourself?
_____yes
_____no
_____sometimes
_____I don’t know because I have never tried
Please check all that apply.
_____I get confused and can’t remember where I am going
_____I can if the driver calls out the stop
_____I probably could with training
_____other (describe)__________________________________________________
14.Are there are any conditions which limit your ability to use the accessible, fixed-route city bus service?
_____no
_____yes (please describe very specifically)_________________________________
____________________________________________________________________
Travel training is personal one-on-one instruction that teaches an individual how to use the accessible, fixed-route city bus service.
15.Have you ever had any personal instruction to use the accessible, fixed-route city buses?
_____no
_____yes, I received personal instruction through an agency (name)______________
_____yes, I received personal instruction from a friend/relative
Indicate all of the skills you learned.
_____to travel to and from bus stops
_____to cross streets
_____to ride on specific routes (please list the routes)__________________________
_____reading bus schedules and planning trips
_____other (describe)___________________________________________________
Did you complete the above described instruction?
_____yes
_____no
16.StarTran offers free travel training to anyone interested in learning how to ride the accessible, fixed-route buses. Would you be interested in getting information about this service?
_____yes
_____no
Please have this page completed before returning your application. Any one of the professionals listed may sign the application. If this page is not signed by professional, the application will be returned to you which will delay the eligibility determination process.
PROFESSIONAL VERIFICATION FORM |
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Please check one: |
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vocational rehabilitation counselor |
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psychiatrist |
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speech pathologist |
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physician’s assistant |
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special education teacher |
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physician |
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social worker/case worker |
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physical therapist |
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senior program director |
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occupational therapist |
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respiratory therapist |
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nurse practitioner |
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mental health counselor |
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nurse |
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psychologist |
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chiropractor |
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recreation therapist employed by a medical facility |
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The Americans with Disabilities Act of 1990 (ADA) is a civil rights bill which requires public transit agencies to provide paratransit service to people whose disabilities prevent them from using accessible, fixed-route bus service some or all of the time. People may be eligible for the paratransit service if, BECAUSE OF A DISABILITY, they
1.require a lift-equipped trip and the bus does not have a lift
2.are unable to independently get to and from a bus stop or on or off an accessible bus, or
3.are unable to understand how to complete a bus trip
The information you provide will enable us to make an appropriate determination for this applicant. Professional verification is used to verify the applicant’s responses on the application. The professional may be contacted for further information regarding the responses.
All information will be kept confidential. Thank you for your assistance.
Applicant’s name:
Medical diagnosis, physical, or cognitive condition which prevents the application from riding an accessible, lift-equipped, fixed-route city bus:
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If yes, for how long? |
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I certify that the information contained in this application is true and correct to the best of my knowledge and ability.
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Date: |
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