Sts Application Form – Fill Out and Use This PDF

SPECIAL TRANSPORTATION SERVICE (STS) APPLICATION FORM

I. APPLICANT SECTION:

S.S.#:(9 digits) __ __ __ - __ __ - __ __ __ __ Date of Birth: ___ / ___ / ___ Sex: [ ] Male [ ] Female

Last Name:___________________________ First Name: ____________________							M.I.: _________
Street Address:________________________________________ Apt.#: ______
City: _________________ State: ______ Zip Code: __________ Home Phone:(							)______________
Is this a [ ] House [ ] Apartment		[ ] Nursing Home		[ ] ACLF		[ ] Boarding Home
Applicant's weight:_____lbs. Wheelchair:(if applicable) weight ______lbs,						length______ , width______.
EMERGENCY CONTACT: Name and telephone number of someone we can call in an emergency.
Name:____________________________ Relationship:_____________________ Phone:(							)______________
ETHNICITY: (for statistics only, optional )
[ ] White Non-Hispanic [ ] Black Non-Hispanic [ ] Hispanic					[ ] Other (specify) ______________
A. If you use a wheelchair, can you transfer with minimal assistance into a sedan?______Yes ______No
Type of wheelchair: [	] Manual	[ ] Motorized	[ ]	Scooter	(Three wheeled)
B. If someone assisted the client to complete this form, please specify;
Name:____________________________ Relationship:_____________________ Phone:(							)______________
If you need to have information given to you in an accessible format, please check one:
[ ] Braille	[ ] Large Print		[ ] Audio		[ ] Computer Disk (ASCII)

II. APPLICANT'S RELEASE:

The following information is requested to determine when and under what circumstances the applicant can use the County bus, rail, or mover service and when Special Transportation Service (STS), van/sedan shared-ride paratransit service, is required.

I understand that the purpose of this form is to determine if I am eligible for Miami-Dade Transit Ageny’s (MDT) Special Transportation Service (STS) in accordance with the American with Disabilities Act (ADA) of 1990 complementary paratransit service requirement. 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 form is true and correct. I understand that providing false or misleading information could result in my eligibility status being re-examined as well as prosecution to the maximum extent allowed by the laws of the State of Florida. I hereby authorize my medical representative to release any and all information required by the MDT Paratransit Certification Enrollment Office regarding my medical condition for the purpose of determining my eligibility to use Special Transportation Service (STS).

Applicant's Signature:_____________________________________ Date:____________________

If applicant is unable to sign this form, he/she may have someone sign and certify on applicant's behalf.

Signing for applicant:______________________________________ Date:_____________________

Print Name:_______________________________Relationship to applicant:___________________________

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SPECIAL TRANSPORTATION SERVICE (STS) APPLICATION FORM

III.MEDICAL VERIFICATION (to be completed by a Florida licensed physician)

The Americans with Disabilities Act of 1990 (ADA) requires all public entities operating fixed-route transportation service for the general public to also provide complementary paratransit service to persons unable to use the fixed-route system. Miami-Dade Transit (MDT), Special Transportation Service (STS) provides complementary paratransit shared ride (i.e. van/sedan) service to individuals certified as ADA paratransit eligible. The applicant who has asked you to review and sign this form is applying to MDT to be considered eligible for this service. This application form will assist MDT to determine when and under what circumstances the applicant can use Metrobus, Metrorail, or Metromover service and when they require paratransit service. ADA/STS van/sedan shared-ride service is intended only for those trips that the person cannot make on the bus/rail/mover system.

STS Eligibility Criteria:

Applicants shall be individually evaluated, and eligibility shall be determined based on a functional ability to use conventional public transportation: Metrobus, Metrorail, and Metromover. Functional inability to use public transportation includes the Americans with Disabilities Act (ADA) Categories 1, 2, and 3 as described in this application.

A. AMERICANS WITH DISABILITIES ACT (ADA) CATEGORIES:

Check the categories of eligibility that you recommend should apply.

1.[ ] The individual is unable, as a result of a physical or mental impairment (including a vision impairment), and without the assistance of another individual, (except the operator of a wheelchair lift or other boarding device), to board, ride, or disembark from an accessible bus or rail vehicle.

2.[ ] The individual needs the assistance of a wheelchair lift or other boarding assistance device and is able, with such assistance, to board, ride, and disembark from accessible transit vehicles. (The individual would be eligible if an accessible vehicle is not available.)

3.[ ] The individual has a specific impairment-related condition which prevents the individual from traveling to or from: Metrobus; Metrorail; and/or Metromover stops/stations.

4.[ ] Check here, if none of these categories apply.

Medical Representative’s Letterhead Or Prescription Form Requirement:

In order to process this applicant’s request to become a qualified STS rider, we require that the medical certification section of this form be completed, and a letterhead or prescription form with the name and address of both the medical representative and the applicant be attached to this application. To expedite applicant processing, please attach objective medical findings which substantiate the disability. Examples include:

EEG or Neuropsychological Evaluation with FSIQ

Snellen (visual accuity) and/or Perimeter Chart (field of vision) Report(s)

Elisa Western Blot result reading CD4 + counts

X-ray, MRI, or CAT Scan Findings

Respiratory FVC/FEV1

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SPECIAL TRANSPORTATION SERVICE (STS) APPLICATION FORM

III.MEDICAL VERIFICATION (To be completed by a licensed physician)

B.INDICATE THE TYPE AND NATURE OF THE INDIVIDUAL’S DISABILITY(IES).

CHECK AS MANY ITEMS AS MAY BE APPLICABLE. (SEE STS ELIGIBILITY CRITERIA)

1.MOBILITY IMPAIRMENT:

a.[ ] Non-ambulatory disability (requires wheelchair to travel). Please specify the condition which requires full time use of a wheelchair _____________________________________________________

b.[ ] Ambulatory disability(ambulation may be limited, but able to walk with or without mobility aid, may use wheelchair but can transfer to a seat with little or no assistance).

I. Amputation (detail extremity): _______________________________________________________

II. [ ] Stroke without Hemiplegia III. [ ] Stroke with Hemiplegia IV. [ ] Brain/Spinal Nerve Trauma V. [ ] Other: _________________________________________

Date disability started: _______________ (Please attach EEG or neuropsychological evaluation report)

2. NEUROLOGICAL DISABILITY(motor dysfunction):

(Please attach EEG or neuropsychological evaluation report)
a. [	] Multiple Sclerosis	b.[ ] Epilepsy	c. [ ] Muscular Dystrophy	d. [ ] Cerebral Palsy
e. [	] Parkinson’s	f. [ ] Alzheimer’s	g. [ ] Other _____________________________________

3.VISUAL DISABILITY:

a.[ ] Totally blind

b.[ ] Legally blind, If this person is legally blind complete the following:

Corrected visual acuity:	Right Eye_____ Left Eye_____(Please attach Snellen reports both eyes)
Corrected field of vision:	Right Eye_____ Left Eye_____(Please attach Perimeter chart reports both eyes)

4.COGNITIVE DISABILITY: a.Type of mental impairment:

[	] Emotional	[	] Autism	[	] Adult retardation	[ ] Dementia
[	] OBS	[	] Alzheimer’s	[	] Developmental disability	[	]	Other

___________________

(Please attach EEG or neuropsychological evaluation showing full scale intelligent quotient “FSIQ” or mental age,

as applicable.)
b. Level of mental impairment:	[	] Mild	[	] Moderate [ ] Severe [ ] Profound, I.Q.:________
5. UNCONTROLLED FATIGUE:				(Must Specify)
a.[ ] Radiation/Chemo b.[ ] Dialysis		If either		a. or b. is marked please provide the following:
Treatment Schedule (or duration): ________			Treatment Start & expected End date: ______ thru ______

Treatment Center: ________________________________ Address: _________________________________

c.[ ] HIV (Please attach Elisa, Western Blot result reading CD4+ counts.) d.[ ] Other _________________

6.IMPAIRMENT RELATED CONDITION:

a. [ ] Arthritis (Please attach MRI/CAT/X-ray findings or operative reports of area affected)

{Functional Classification ____ Anatomical Stage ____}	b. [ ] Other________________
b. [ ] Cardiac (Please attach EKG or operative findings)	_________________________
{Functional Classification ____ Therapeutic Classification ____}	_________________________

c.[ ] Respiratory (Must specify) {FVC ____ FEV1 ____} (Please attach oxymetric capability report)

C. DESCRIBE IN DETAIL THE APPLICANT’S PRIMARY DISABILITY: (BE SPECIFIC)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

______________________________________________________________________________________________________

D. IS THIS DISABILITY: [ ] Perm [ ] Temp; (If temporary, date of disability ________, & length of recovery _______)

E. IS THIS DISABILITY CONTROLLED BY MEDICATION? [ ] Yes [ ] No

Explain:____________________________________________________________________________________

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SPECIAL TRANSPORTATION SERVICE (STS) APPLICATION FORM

III.MEDICAL VERIFICATION (To be completed by a licensed physician)

F. INDICATE THE TASKS RELATED TO USING PUBLIC TRANSIT THAT THE APPLICANT WOULD FIND IMPOSSIBLE (NOT DIFFICULT) TO DO. CHECK ALL THAT APPLY:

[	] No limitations that would prevent the use of bus/rail service	[	] Enduring warm weather
[	] Boarding vehicle without a wheelchair lift	[	] Waiting thirty minutes
[	] Enduring common weather conditions	[	] Recognizing a bus stop
[	] Identifying a public transit vehicle	[	] Recognizing destinations if stops are
[	] Understanding/handling bus fare (money) transactions		announced
[	] Handling changes in normal routine	[	] Climbing 1-3 steps

[] Walking more than ______ blocks (Must stipulate number of blocks)

These limitations apply:	[ ] Always	[	] Usually	[ ] Occasionally [		] Rarely
G. MOBILITY AID: [	]Wheelchair	[	]Walker	[	]Crutches	[ ]Braces	[ ]Service Animal
[ ]None		[ ] Cane		[	]Other _____________________

H. REQUIRED MODE OF TRANSPORTATION: Please indicate the type of transportation required by the applicant based on his/her functional ability.

[ ] Ambulatory (van, sedan) [ ] Wheelchair Transferable(van,sedan) [ ] Wheelchair Confined(lift van)

I. BASED ON THE INDIVIDUAL'S DISABILITY, DO YOU RECOMMEND HIM/HER TO BRING A

PERSONAL CARE ATTENDANT ON EACH TRIP?

[ ] Yes [ ] No

J. PLEASE ATTACH PERTINENT MEDICAL DOCUMENTATION (E.G. EVALUATIONS, TEST RESULTS, NOTES, REPORTS, ETC.) THAT WOULD HELP TO EXPLAIN THE DIAGNOSIS OR LIMITATIONS ON THE APPLICANT'S ABILITY TO USE METROBUS, METRORAIL, OR METROMOVER.

NOTE: Failure to attach documentation will delay the eligibility determination process and will require that MDT contact your office to obtain pertinent documentation before rendering a decision.

IN SIGNING, I ACKNOWLEDGE THAT, TO THE BEST OF MY KNOWLEDGE, THE INFORMATION IN THIS EVALUATION FORM IS TRUE AND CORRECT. FURTHERMORE, I CERTIFY THAT, I HAVE ATTACHED OBJECTIVE MEDICAL TESTS/DOCUMENTATION WHICH SUBSTANTIATE THE ABOVE STATEMENTS. I UNDERSTAND THAT PROVIDING FALSE OR MISLEADING INFORMATION COULD RESULT IN THE RE- EXAMINATION OF THE ELIGIBILITY STATUS OF THE APPLICANT AS WELL AS PROSECUTION TO THE MAXIMUM EXTENT ALLOWED BY THE LAWS OF THE STATE OF FLORIDA.

[ ] YES, I have attached the required medical documentation

____________________________________________________
Print or Type Name of Physician	State of Florida License#	Signature

________________________________________________________(____)_________(____)__________

Office Address

City

State

Zip Code Telephone

Fax #

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