The River Valley Metro Mass Transit District offers an essential service through its Metro Plus Paratransit system, designed to aid individuals whose disabilities prevent them from using regular bus services effectively. The heart of accessing these tailored transport services lies in the completion of the Metro Plus Paratransit Eligibility Application form. This comprehensive form, requiring thorough completion and returning to the Bourbonnais office, gathers crucial personal information, including name, contact details, and an acknowledgment of the data's accuracy under penalty of service denial if falsified. It notably includes space for the applicant to authenticate the information or for another to vouch for the applicant's condition, coupled with a mandate for the release of medical or psychological records by the applicant themselves, not by a healthcare professional. This approach ensures privacy and control remain with the applicant, although it underscores that verification by authorized professionals such as licensed physicians or certified rehabilitation counselors, while not a guarantee of eligibility, is vital for the assessment process. Additionally, it inquires about current means of travel, potential requirements for assistance, and both disability and functional limitation specifics to thoroughly evaluate the applicant's need for paratransit services. This form is not just a bureaucratic step but a gateway to increased mobility and independence for those facing significant challenges in navigating public transportation.
| Question | Answer |
|---|---|
| Form Name | River Valley Metro Eligibility Application Form |
| Form Length | 7 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 45 sec |
| Other names | ADA_Eligibility _Application_01 11 metro online form |
Metro Plus Paratransit
ELIGIBILITY APPLICATION
Form must be filled out completely
Please Return Completed Form to: |
River Valley Metro Mass Transit Dist. |
|
1137 E. 5000 N. Rd. |
|
Bourbonnais, IL. 60914 |
Personal Information
1.Name
2.email address ________________________________________________
3.Address
|
City |
|
State |
|
|
Zip |
|
||
4. |
Telephone No. (Home) |
|
|
|
(Work) |
|
|||
5.Date of Birth
Certification
A.I certify that the information I give in this application is true and correct. I understand that falsification of information may result in denial of service. I understand all information will be kept confidential and only the information required to provide the services I request will be disclosed to those who perform those services.
Applicant Signature
Date
B.Person completing form other than applicant (please check one):
I certify that the information provided in this application is true and correct, based upon information given to me by the applicant.
1
I certify that the information provided in this application is true and correct, based upon my knowledge of the applicant’s health condition
or disability.
Exceptions or Additions:
Print Name |
|
Date |
Agency
Signature
Daytime Phone
Relationship to Applicant
Address
City |
|
State |
|
Zip |
Authorization For Release Of Medical/Psychological Records
(Must be completed by applicant, Not Physician)
THIS SECTION IS TO BE COMPLETED BY YOU, THE APPLICANT, AND NOT BY YOUR PHYSICIAN, PSYCHIATRIST OR HEALTH CARE PROFESSIONAL. A SEPARATE FORM MAY BE SENT TO HIM/HER TO CONFIRM THE INFORMATION YOU HAVE PROVIDED.
NOTE: Disability verification by a qualified professional does NOT guarantee eligibility, but it can play a major role in the eligibility determination
process. While verification by a physician is NOT required, it is important that any professional that verifies another individual’s disability be familiar not only with that person’s particular disability, but with an individual’s ability or inability to travel on Metro’s regular bus system. This information is confidential and will
NOT be shared with any other person or agency, with the possible exception of another transit provider or transportation program to facilitate travel in those areas.
NOTE: Only the following professionals are authorized to verify your disability:
2
Licenses Physician, Psychiatrist, Physical Therapist (PT), Occupational Therapist (OTR), Certified Rehabilitation Counselor (CRC), and Orientation and Mobility Specialist (O&M).
Name of Professional: ______________________________________________________
Agency: ___________________________________________________________________
Address: __________________________________________________________________
City: _________________________________ State: ___________ Zip: _______________
Telephone Number: ________________________________________________________
Name of Professional: ______________________________________________________
Agency: ___________________________________________________________________
Address: __________________________________________________________________
City: __________________________________ State: ___________ Zip: ______________
Telephone Number: ________________________________________________________
APPLICANT INFORMATION
NAME (PRINT): ___________________________________________________________
SIGNATURE: ___________________________________ DATE: ___________________
PARENT OR LEGAL GUARDIAN INFORMATION *
NAME (PRINT): ___________________________________________________________
SIGNATURE: ____________________________________ DATE: ___________________
*NOTE: Applicant signature or Parent/Legal Guardian signature is REQUIRED for application processing.
3
Present Means Of Travel
1.Have you ridden a River Valley Metro’s fixed route bus in the last 3 months?
Yes
No
If No, have you attempted to use a fixed route bus in the last 3 months?
Yes
No
If Yes, please explain what happened
2.What assistance do you need when traveling? Check all that apply
____ Support Cane |
____ Electronic Travel Aid |
____ Long Cane/White Cane |
____ Personal Care Attendant |
____ Service Animal |
____ Powered Scooter |
____ Crutches |
____ Prosthesis |
____ Wheelchair (Power) |
____ Wheelchair (Manual) |
____ Walker |
____ None |
____ Need help transferring to a seat
____ Other
If you use a wheelchair or scooter/cart, is it
_____More than 30 inches wide OR
_____More than 48 inches long, OR
_____Weigh more than 600 pounds when empty?
3.Do you require a Personal Care Attendant (PCA)* when you travel?
Always |
Sometimes |
Never
If Always or Sometimes, provide name of PCA:
*A PCA is someone designated or employed by a person with a disability to assist that person in meeting his or her personal needs and/or to facilitate travel for a specific trip. A PCA is not a companion.
4
Transit Travel/Training Information
1.Do you know where to get off the bus, or can you find out?
Always |
Sometimes |
Never |
If Sometimes, please explain.
2.Have you ever had any training to use the fixed route bus service?
Yes |
In Process |
No |
Disability and Functional Limitation Information
1.Please describe your current disability (list all applicable disabilities).
2.Is your health condition or disability temporary?
Yes
No
If Yes, expected end date ____/____/____ |
or (____ months) |
3.Does your health condition or disability change from
Yes
No
If Yes, please explain
5
4.Are there any other conditions (such as extreme hot or cold weather) that limit your ability to use the fixed route bus service?
Yes
No
If Yes, please explain
5.Can you transfer from one fixed route bus to another?
Yes |
Sometimes |
No
If Sometimes or No, please explain
6.Can you use the telephone or TTY to make calls?
Yes |
Sometimes |
If Sometimes or No, please explain
No
7.Can you follow instructions?
WRITTEN INSTRUCTIONS: |
Yes |
VERBAL INSTRUCTIONS: |
Yes |
If Sometimes or No, please explain
Sometimes
Sometimes
No
No
8.Are you able to make your way to and from the nearest bus stop to your home, either with or without mobility aids?
Yes |
Sometimes |
No
If Sometimes or No, please explain
6
9.Can you wait outside for 15 minutes?
Yes |
Sometimes |
Explain if Sometimes or No
No
10.Are you able to travel ¼ mile (4 blocks or less), either with or without mobility aids?
Yes |
Sometimes |
No
Explain if Sometimes or No
11.If using a wheelchair, are you able to transfer from the chair to a bus seat?
Yes
No
If Yes describe limitations:
Miscellaneous
1.Check all that apply if you are NOT currently riding fixed route buses:
____ I don’t know how to ride the regular fixed route bus.
____ I’m afraid to ride the regular fixed route bus.
____ I don’t want to ride the regular fixed route bus.
____ It is too far to get to the regular fixed route bus.
____ The ground is too uneven or steep for me to get to the bus stop.
____ There are no sidewalks where I live.
____ I need a wheelchair lift or ramp to board the bus.
____ I can use the regular fixed route bus under certain circumstances.
____ I cannot recognize a destination or landmark.
____ Other (Please explain)
2.Are there any other aspects of your health condition or disability that we should know about?
Yes
If Yes, please explain
No
7