APPLICATION INSTRUCTIONS
All applicants must submit a complete application which includes BOTH FORMS
(1)The Certiication Questionnaire Form
(2)The Professional Veriication Form
STEP 1 COMPLETE THE CERTIFICATION QUESTIONNAIRE
The Certiication Questionnaire should be illed out by
the applicant or the applicant’s advocate. The form must be illed out in its entirety. It should be signed by the applicant or the applicant’s guardian and anyone who assisted the applicant in completing the application.
CERTIFICATION
QUESTIONNAIRE
Americans with Disabilities Act (ADA) | Paratransit Eligibility
1. |
See application Instructions |
We do not |
2. |
If you have additional questions call Metro Mobility |
accePt |
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Customer Service at (651) 602-1111 voice, (651) 221-9886 TTY. |
aPPlications |
3. This form is incomplete if it is NOT ACCOMPANIED BY COMPLETED |
by fax |
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PROFESSIONAL VERIFICATION. |
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This application and future written information are available in large print. Does large print better suit your needs?
PART 1 APPLICANT DATAPlease Print or tyPe
Name: ______________________________________________________________________________________
STEP 2 COMPLETE THE PROFESSIONAL VERIFICATION FORM
The Professional Veriication Form must be completed by one of the following professionals who are familiar with the applicant’s condition:
•Physicians or Psychiatrists
•Occupational Therapists
•Psychologists
•Physical Therapists
•Licensed Independent Social Workers (LISW, LICSW)
•Recreational Therapists
•Speech/Language Pathologists
•Certiied Orientation and Mobility Specialists
•Registered Nurses (RN)
•Doctors of Chiropractic (DC)
ELIGIBILITY APPLICATION
PROFESSIONAL VERIFICATION
Americans with Disabilities Act (ADA)
1. |
Complete and sign the “Authorization to Release Information”. |
We do not |
2. |
Send to your designated professional. |
accePt |
3. |
Wait for the professional to return this form to you. |
aPPlications |
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Check back with your professional if you don’t receive your information. |
by fax |
4.This form is incomplete if it is NOT ACCOMPANIED BY COMPLETED CERTIFICATION QUESTIONNAIRE.
SECTION A RELEASE INFORMATION |
Please Print or tyPe |
AUTHORIZATION TO |
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(WHEN COMPLETE SEND TO THE PROFESSIONAL YOU NAMED) |
Applicant’s Name: First |
Middle Initial |
Last |
Birth Date:______/______/______ |
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Applicant’s Address: ________________________________________________ Apt.#:____________________
City: ___________________________________________ State:_____________ Zip Code: ________________
Applicant’s Telephone Number ( |
) ______________________________ |
I authorize the following professional to release to the MMSC speciic information as requested. It is my understanding that the information released will be used solely to determine my ADA paratransit eligibility. I understand that I may revoke this authorization at any time. Unless revoked, this form will allow that professional listed below to release information described for six months after the date appearing below.
Name of Professional: _______________________________________________ Title:_____________________
Applicant’s Signature: ____________________________________________ Date: ______/______/______
Guardian’s signature required if the applicant is not his/her own guardian,
Guardian’s Signature:_____________________________________________ Date: ______/______/______
To complete the Professional Veriication Form
1.Complete and sign the Authorization to Release Information.
2.Send the Professional Veriication Form to your designated professional.
3.Wait for your professional to return the Professional Veriication Form to you. Check back with your professional if you have not received the form back in a timely manner.
STEP 3 SUBMIT BOTH FORMS TOGETHER
Submit both the Certiication Questionnaire and the Professional Veriication Form in the same envelope to
Metro Mobility Service Center
390 N. Robert Street
Saint Paul, MN 55101-1805
WE DO NOT ACCEPT APPLICATIONS BY FAX OR E-MAIL |
See additional info on back |
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STEP 4 IN-PERSON ASSESSMENT
Usually the forms provide Metro Mobility Staff with all of the information needed to make a determination on eligibility. Sometimes however more information is needed. When this happens an applicant may be asked to come in for an “in-person assessment.”
This assessment may include:
•A conversation about the applicant’s current mobility. The Metro Mobility evaluator will talk with you about how you currently get around.
•A pretend bus trip on the computer. This standardized test is designed to measure a person’s cognitive ability to use regular ixed-route transit. (Functional Assessment of Cognitive Transit Skills or FACTS for short.)
•A walk outside or through the skyway. This will help determine things such as physical ability to get to the regular ixed-route bus as well as memory and landmark recognition.
•A standard walking and balance test. This standardized test measures a person’s risk of falling. (Tinetti Gait and Balance Test.)
PLEASE NOTE THAT APPLICANTS WHO NEED TO COME IN FOR IN-PERSON ASSESSMENTS WILL STILL HAVE THEIR APPLICATIONS PROCESSED WITHIN 21 CALENDAR DAYS.
COMMON ISSUES
In order to make a determination within 21 calendar days the Metro Mobility Service Center must have a complete application. There are several things which may cause an application to be incomplete. By double checking these things PRIOR to submitting your application you may avoid delays in processing.
1.One of the forms is missing. Your application must contain both the Certiication Questionnaire and the Professional Veriication. Please ensure both are submitted in the same envelope.
2.One of the forms is not signed. Both the Certiication Questionnaire and the Professional Veriication must be signed. If either the applicant or the professional forgets to sign the form it is considered incomplete.
3.The professional credentials are missing. Professionals must include their titles and credentials when signing the Professional Veriication.
Jane Doe X (Incomplete) Jane Doe M.D. |
(Complete) Jane Doe R.N. |
(Complete) |
AN INCOMPLETE APPLICATION WILL BE RETURNED TO THE APPLICANT ONE (1) TIME. IF IT IS SUBMITTED A SECOND TIME AND IS STILL INCOMPLETE IT WILL BE HELD FOR 60 DAYS BY THE METRO MOBILITY SERVICE CENTER BEFOREIT IS DISCARDED.
APPLICATIONS MUST BE PROCESSED WITHIN 21 CALENDAR DAYS. IF YOUR PROPERLY COMPLETED AND SUBMITTED APPLICATION IS NOT PROCESSED WITHIN 21 DAYS, YOU WILL BE GRANTED PRESUMPTIVE ELIGIBILITY FOR METRO MOBILITY SERVICE UNTIL YOUR APPLICATION IS PROCESSED.
Questions? Please call 651-602-1111
CERTIFICATION
QUESTIONNAIRE
Americans with Disabilities Act (ADA) | Paratransit Eligibility
1.See application Instructions
2.If you have additional questions call Metro Mobility
Customer Service at (651) 602-1111 voice, (651) 221-9886 TTY.
3.This form is incomplete if it is NOT ACCOMPANIED BY COMPLETED PROFESSIONAL VERIFICATION.
WE DO NOT ACCEPT APPLICATIONS BY FAX
This application and future written information are available in large print. Does large print better suit your needs?
Name: ______________________________________________________________________________________
FirstMiddle InitialLast
Street Address: ____________________________________________________ Apt.#:____________________
City: ______________________________________________________________ Zip Code: ________________
Day Telephone: ( |
) ________________________ Evening Telephone: ( |
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Email Address: _____________________________________________________ |
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I prefer communication via email: ____Yes ____No |
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Birth Date:______/______/______ |
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Do you have a Minnesota state ID card or Minnesota driver’s license? |
Yes |
No |
ID # ______________________________ License # ______________________ Expiration Year: __________
Mailing Address (if different from above)
Street Address: ____________________________________________________ Apt.#: __________________
City: ______________________________________________________________ Zip Code: ______________
Emergency Contact Person
Name: _____________________________________________________________________________________
First |
Middle Initial |
Last |
Day Telephone: ( |
) _______________________ Evening Telephone: ( |
) _______________ |
1.Are you able to travel in an automobile? ____Yes ____No
2.If you use a wheelchair or scooter:
Is it more than 30 inches wide? ____Yes ____No
Is it more than 48 inches long? ____Yes ____No
Is the combined weight of device and occupant more than 600 pounds? ____Yes ____No
3. Which of the following assistive devices, if any, do you use? (Please check all that apply.)
Cane |
Manual Wheelchair |
Boarding Chair |
Prosthesis |
White Cane |
Powered Wheelchair |
Service Animal |
Communication Aid |
Walker |
Powered Scooter/ |
Portable Oxygen |
Other (please describe): |
Crutches |
Cart |
Transfer Board |
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If you selected Wheelchair or Scooter, would you prefer/need to use the device while riding in Metro Mobility Vehicles? ____Yes ____No ____Sometimes
4.Does your health condition/disability require you to use Metro Mobility service:
Seasonally (Nov. - Apr.)
Permanently |
Temporarily |
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If temporarily, for how long? |
Week(s) |
Month(s) |
5.Does your health condition/disability change from day to day in ways that occasionally disrupts your ability to use regular-route city bus service? ____Yes ____No
If yes, please explain: ______________________________________________________________________
6.When using Metro Mobility service, does your health condition/disability require you to travel with someone to assist and/or supervise you? ____Yes ____No
PART 2 QUESTIONS ABOUT USING
REGULAR-ROUTE PUBLIC TRANSIT
Complete Part 2 even if you are unable to use regular-route city bus service. This information will assist us in determining how your disability/health condition affects your ability to use regular-route city bus
service.
7. Do you now independently use regular-route city buses? ____Yes ____No ____Sometimes
If “Yes” or “Sometimes,” how many times? |
per week |
per month per year |
Which of the following best describes how you use regular-route city buses?
To travel to and from one destination only
To travel to and from a few destinations
To travel to and from many different destinations
Explain what prevents you from independently using regular-route city bus.
8. Have you ever had training to use the regular-route city buses? ____Yes ____No
9. Using a mobility aid or on your own, how far are you able to travel without the assistance of
another person? |
3 blocks |
6 blocks |
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9 blocks or more |
less than 3 blocks |
10.I can wait for a regular-route city bus (check all that apply):
Only if there is a bench or shelter
Up to 15 minutes |
More than 15 minutes |
11.Please check all the categories below as they relate to your ability to use regular-route city buses:
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I am: |
Yes |
No |
Sometimes |
A. |
Able to tolerate very hot or very cold weather |
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B. |
Able to recognize destinations, bus stops, or landmarks |
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C. |
Able to tolerate air pollution (smog, fumes, perfume) |
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D. |
Free from night blindness |
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E. |
Able to recognize printed information |
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F. |
Able |
to hear and process spoken words or auditory information |
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G. |
Able to communicate needs |
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H. |
Able to follow directions |
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I.Able to deal with unexpected situations or changes in routine
(example: bus detours)................................................................... 
J.Able to safely and effectively travel through crowded and/or
complex facilities............................................................................ 
K. Able to recognize changes in terrain.................................................. 
L.Able to travel independently along sidewalks and other
pedestrian ways .............................................................................. 
M. Able to cross streets independently................................................... 
N. Able to ind the correct bus stop ....................................................... 
O. Able to identify the correct bus.......................................................... 
P. Able to get on and off a bus using the lift if necessary...................... 
Q. Able to deposit fare into the fare box or show bus pass ................... 
R.Able to get to a seat/wheelchair position and remain seated
during a bus trip .............................................................................. 
S. Familiar with what to do if I miss my bus........................................... 
If you checked “No” or “Sometimes” to any of the items in question 11, please explain:
More Space Provided On The Next Page
PART 3 APPLICANT SIGNATURE
The information provided on this form is private data and is used to determine ADA paratransit eligibility. The ability to determine your eligibility is based on receiving all of the information requested on this form. All medical or locational information pertaining to application for or users of ADA paratransit service is private. Any other information cannot be released to anyone else, unless the applicant or user authorizes the release in writing. If you are determined ADA paratransit eligible, information about your eligibility status will be entered into a database maintained by the Minnesota Department of Public Safety, Driver and Vehicle Services Division. This information could be used by Drivers License Division of the Depart- ment of Public Safety to (1) Reexamine your driving ability or, (2) Demand that you surrender your license if a severe disabling condition has developed since the current license was issued.
I certify that all information on this application form is accurate. I understand that misinformation or misrepresentation of facts will be cause for disqualiication or rejection of my ADA eligibility. I also understand that additional information relating to my health condition or disability may be required to determine eligibility. This information may be obtained through an in-person assessment or by requesting information from a professional who understands my health condition or disability. Additional information will be required only when the information provided on the application form does not clearly determine ADA paratransit eligibility.
Applicant’s Signature:_____________________________________________ Date:______/______/______
*If the applicant is not his/her own guardian, the following information about the guardian is required:
Guardian’s Name: (please print) _______________________________________________________________________________
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First |
Middle Initial |
Last |
Day Phone: ( |
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Guardian’s Signature: _____________________________________________ Date:______/______/______
*If someone other than the applicant or the applicant’s guardian is preparing this form, please provide the following information about the preparer:
Name: (please print) _________________________________________________________________________________________
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First |
Middle Initial |
Last |
Day Phone: ( |
) ______________________________________________________ |
Preparer’s Signature:______________________________________________ Date:______/______/______
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ELIGIBILITY APPLICATION PROFESSIONAL VERIFICATION
Americans with Disabilities Act (ADA)
1.Complete and sign the “Authorization to Release Information”.
2.Send to your designated professional.
3.Wait for the professional to return this form to you.
Check back with your professional if you don’t receive your information.
4.This form is incomplete if it is NOT ACCOMPANIED BY COMPLETED CERTIFICATION QUESTIONNAIRE.
WE DO NOT ACCEPT APPLICATIONS BY FAX
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AUTHORIZATION TO |
PLEASE PRINT OR TYPE |
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SECTION A RELEASE INFORMATION |
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(WHEN COMPLETE SEND TO THE PROFESSIONAL YOU NAMED) |
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Applicant’s Name: First |
Middle Initial |
Last |
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Birth Date:______/______/______ |
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Applicant’s Address: ________________________________________________ Apt.#:____________________
City: ___________________________________________ State:_____________ Zip Code: ________________
Applicant’s Telephone Number ( |
) ______________________________ |
I authorize the following professional to release to the MMSC speciic information as requested. It is my understanding that the information released will be used solely to determine my ADA paratransit eligibility. I understand that I may revoke this authorization at any time. Unless revoked, this form will allow that professional listed below to release information described for six months after the date appearing below.
Name of Professional: _______________________________________________ Title:_____________________
Applicant’s Signature: ____________________________________________ Date: ______/______/______
Guardian’s signature required if the applicant is not his/her own guardian,
Guardian’s Signature:_____________________________________________ Date: ______/______/______
SECTION B METRO MOBILITY PROFESSIONAL VERIFICATION FORM
Dear Health Care Professional:
You are being asked to provide information regarding this individual’s disability. The Federal Law is very speciic about ADA para-transit eligibility. The law restricts eligibility to individuals who,
1.as a result of their disability, cannot board, ride, or disembark from a regular ixed route bus or light rail car or
2.have a speciic impairment-related condition which prevents them from getting to or from a bus stop.
PLEASE NOTE: This does not include persons who ind it dificult or uncomfortable to get to and
from bus stops. In providing information you should consider only the presence of a disability or health condition and not the applicant’s age or economic status.
THIS SECTION MUST BE FILLED OUT FOR ALL APPLICANTS
GENERAL INFORMATION
•Describe the diagnosed disability you are currently treating this individual for: _____________________
____________________________________________________________________________________________
• Describe any other health conditions or disabilities with which this individual is diagnosed:__________
____________________________________________________________________________________________
•Date of onset ____/____/____
•Date of last visit ____/____/____
•How long have you worked with the individual? Since ____/____/____
•Is disability temporary ________ or permanent ________ ?
If permanent is disability progressive? ____Yes ____No
If temporary please give best estimate of rate of recovery. ___________________________________
• Is therapy part of treatment? ____Yes ____No If yes, give brief description ______________________
____________________________________________________________________________________________
• Do temperature extremes affect the individual?
(Ex. Heat index of more than 85 degrees or wind chill less than 10 degrees) ____Yes ____No
If yes, how so? _________________________________________________________________________
• Please list all medications. _____________________________ |
____________________________ |
_____________________________ |
____________________________ |
_____________________________ |
____________________________ |
•Is this individual compliant with taking medications? ____Yes ____No
•Does the individual currently uses regular route public transportation? ____Yes ____No ____Not Sure
•Is the individual’s judgment impaired ____Yes ____No
•Is behavioral inhibition impaired? ____Yes ____No
•Can the individual walk? ____Yes ____No
• Does the individual use a mobility aid? ____Yes ____No Please list ____________________________
____________________________________________________________________________________________
•How long has individual been using the device(s)? _____________________________________________
____________________________________________________________________________________________
• How far can the individual travel without the assistance of another person?
3 blocks |
6 blocks |
9 blocks or more |
less than 3 blocks |
•With treatment/therapy will this distance increase? ____Yes ____No
•Please indicate the expected distance after treatment/therapy:
3 blocks |
6 blocks |
9 blocks or more |
less than 3 blocks |
•Give best estimate of length of time required to achieve this improvement. _______________________
____________________________________________________________________________________________
PLEASE COMPLETE ONLY THOSE SECTIONS THAT APPLY TO THIS INDIVIDUAL
NEUROLOGICAL IMPAIRMENT/HEAD INJURY
• Does the individual experience seizures? ____Yes ____No Date of last seizure ______/______/______
•Please give no. of seizures ________ and frequency ____________________________________________
•What type(s) of seizures does patient experience_______________________________________________
•Does individual experience auras? ____Yes ____No
•Is the individual’s judgment impaired? ____Yes ____No
•Is behavioral inhibition impaired? ____Yes ____No
•Does judgment and inhibition impairment prevent the individual from independently traveling outside the home or immediate environment? ____Yes ____No
•When traveling independently does the individual have the ability to: (check all that apply)
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Get help if lost |
Recognize & avoid danger |
Cross streets safely |
Follow written directions |
Communicate needs |
Process information |
Understand and follow schedule to get places on time
• Is there history of Brain Injury ____Yes ____No. Date of injury______/______/______
VISUAL IMPAIRMENT
•Please provide visual acuity measurements and visual ield readings for both eyes. OS: __________________________ OD: ________________________________
•Does the individual require any accommodations, adaptations, low vision aids, etc? Please list:
____________________________________________________________________________________________
____________________________________________________________________________________________
• How does the individual’s visual impairment affect their ability to move about in the environment?
____________________________________________________________________________________________
____________________________________________________________________________________________
• Has the individual received any orientation & mobility (O&M) training? ____Yes ____No
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Questions? Please call 651-602-1111 |
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• Does the individual experience any of the following: |
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Auditory hallucinations |
Visual hallucinations |
Delusions |
Disassociation |
•Does this prevent the individual from being oriented to person, place, and time? ____Yes ____No
•Is the individual currently being treated for any of the following:
Anxiety |
Depression |
Panic attacks |
Schizophrenia |
Other: _____________________ |
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•For anxiety panic attacks please indicate on average the frequency and length of panic attacks. Per day________ Per week________ Per month________ Per year________
Approx. duration: ________
•What technique(s) and/or skills is the individual utilizing to assist in coping with the above issue(s)?
Visualization |
Relaxation techniques |
Positive self-talk |
Aroma therapy |
Other:______________________ |
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•Are these techniques effective in reducing symptoms? ____Yes ____No
•Is there a history of Electroconvulsive Therapy (ECT)? ____Yes ____No ____Unknown
COGNITIVE/MENTAL IMPAIRMENTS
Please list IQ score and GAF score if known. IQ = ___________ GAF = ___________
•Please describe the functional limitations caused by this impairment?
___________________________________________________________________________________________
___________________________________________________________________________________________
•Is the individual’s judgment impaired? ____Yes ____No
•If yes, please describe to what extent or give an example.______________________________________
_________________________________________________________________________________________
• Is the individual able to live independently? ____Yes ____No
Additional Comments: ____________________________________________________________________
___________________________________________________________________________________________
MMSC Staff will make the inal determination of the applicant’s eligibility
Doctor/Health Care Professional Signature: _________________________________________________
PLEASE RETURN FORM TO APPLICANT PLEASE PRINT so that we may contact you if needed Name of Professional: ______________________________________________ Date: ______/______/______
Title: _______________________________________________________________________________________
Street Address:______________________________________________________________________________
City: _____________________________________ State: ________ Zip Code: _________________________
Telephone Number: ( |
) ____________________________ Fax: ( |
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