Metro Mobility Application – Fill Out and Use This PDF

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

STEP 2 COMPLETE THE PROFESSIONAL VERIFICATION FORM

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

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.

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

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: ________________

ID # ______________________________ License # ______________________ Expiration Year: __________

Mailing Address (if different from above)

Street Address: ____________________________________________________ Apt.#: __________________

City: ______________________________________________________________ Zip Code: ______________

Emergency Contact Person

Name: _____________________________________________________________________________________

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

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3. Which of the following assistive devices, if any, do you use? (Please check all that apply.)

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.)

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

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

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9. Using a mobility aid or on your own, how far are you able to travel without the assistance of

10.I can wait for a regular-route city bus (check all that apply):

Only if there is a bench or shelter

11.Please check all the categories below as they relate to your ability to use regular-route city buses:

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

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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) _______________________________________________________________________________

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) _________________________________________________________________________________________

Preparer’s Signature:______________________________________________ Date:______/______/______

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ELIGIBILITY APPLICATION PROFESSIONAL VERIFICATION

Americans with Disabilities Act (ADA)

Applicant’s Address: ________________________________________________ Apt.#:____________________

City: ___________________________________________ State:_____________ Zip Code: ________________

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: ______/______/______

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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? _________________________________________________________________________

•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 ____________________________

____________________________________________________________________________________________

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•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:

•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)?

•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: _________________________

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