Tarc3 Form PDF Details

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Question	Answer
Form Name	Tarc3 Form
Form Length	19 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	4 min 45 sec
Other names	tarc3 paratransit, tarc 3, tarc3 louisville ky, for tarc3

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Transit Authority of River City	www.ridetarc.org
	(502)	585-1234
	TTY (502)	213-3240

Application for TARC3 Transportation

APPLICATION FOR TARC3 TRANSPORTATION

INTRODUCTION

TARC3 is an alternative to regular TARC buses that provides door-to-door, shared- ride public transportation for individuals with disabilities who cannot independently board, ride or exit from TARC’s regular fixed-route buses. Disability alone does not automatically qualify an individual for TARC3 transportation. Note: All TARC buses and trolleys are wheelchair-accessible.




	Ramp on TARC Fixed-route bus			Wheelchair Lift on TARC 3
				Paratransit vehicle

TARC3 transportation is covered under Title II of the Americans With Disabilities Act of 1990, commonly known as the ADA. The ADA is not an affirmative action statute, but rather the ADA extends federal civil rights protection to people who are considered “disabled”.

In general, the transportation that TARC3 provides for people with disabilities must be comparable to the service that is provided for people who are not disabled. This includes the same days and times of operation as well as the same areas that are served by fixed-route buses, though it does not include areas served only by express bus routes. TARC3 operates within a ¾ mile radius of any fixed-route bus line.

Application for TARC3 - Introduction

If either the Application for TARC3 or the TARC3 Medical Form is not in this package, please call the TARC3 Transportation office at 213-3217.

Step1:

PLEASE COMPLETE ALL SECTIONS OF THE APPLICATION THAT APPLY TO YOU.

•Section 1 should be answered by/for every applicant.

•Section 2 should be answered by/for applicants with a mobility disability.

•Section 3 should be answered by/for applicants with cognitive or mental disabilities.

•Section 4 should be answered by/for applicants with vision disabilities.

•Section 5 should be completed by/for each applicant.

•Incomplete or unsigned applications will be returned.

Step 2:

When your Healthcare Provider has completed the TARC3 Medical Form, please sub- mit it to the TARC3 office together with your completed application. Applications and medical forms cannot be accepted if received separately.

Your application and medical form(s) will be reviewed upon receipt in our office. As part of the application process, you may be required to undergo an eligibility screen- ing and/or a functional assessment. You will be contacted if additional information is deemed necessary. Please be patient. An eligibility decision will be made within 21 days of receipt of a completed application and medical form(s).

Applicants who do not agree with the eligibility determination may request an appeal. A detailed description of the appeals process will be included with all denial and con- ditional eligibility determinations.

SECTION 1: APPLICANT INFORMATION

TO BE ANSWERED BY ALL TARC3 APPLICANTS

PLEASE PRINT

Last Name __________________________ First _______________________ MI ___

Address ____________________________________________________Apt______

(do not use PO box numbers)

City ______________________________State ________ Zip Code _____________

Name of subdivision or apartment complex __________________________________

What streets border your neighborhood? ____________________________________

_____________________________________________________________________

Mailing address if different from above ______________________________________

Daytime phone # _______________________Evening Phone #__________________

TTY # for the deaf & hard of hearing _______________________________________

Date of birth_________________ / _________________ / _________________

Do you speak English? ___ Yes ___ No If no, what language? ________________

Do you need information in the following alternative formats?

______ Large Print ______ Audio Tape

E-mail address ________________________________________________________

Section 1 - Continued

Emergency Contacts:

(1)Name ____________________________________________________________

Relationship to Applicant ________________________________________________

Address _____________________________________________________________

Daytime phone # ______________________Evening Phone # _________________

(2)Name ____________________________________________________________

Relationship to Applicant ________________________________________________

Address _____________________________________________________________

Daytime phone# _______________________Evening Phone# __________________

CHECK ALL THAT APPLY
1. How do you travel now?
______ Walk	______ Drive a Car
______ Taxi	______ Ride in a Car
______ Bus	______ Other ____________________

2. Which of these aids do you currently use?

______ Portable Oxygen	______ Crutches / Leg Brace / Prosthetic Leg
______ Straight Cane	______ Human Guide
______ 3 or 4-Pronged Cane	______ White Cane
______ Walker	______ Dog Guide
______ Manual Wheelchair	______ Alphabet Board
______ Powered Wheelchair	______ Picture Board
______ Powered Scooter	______ Service Animal

______ Other ____________________________________________________

Section 1 - Continued

3. Does the total weight of your wheelchair/scooter and yourself exceed 600 pounds?

______ Yes

______ No

______ Don’t Know

4. Does your wheelchair/scooter exceed 30” in width or 48” in length?

______ Yes

______ No

______ Don’t Know

5.All TARC fixed route buses and trolleys have lifts or ramps to accommodate people with impaired mobility, whether or not they use a mobility aid. Any passenger may request the use of the lift or ramp to board or exit the bus. Do you need the lift or ramp to get on and off a TARC bus or trolley?

______ Yes ______ No

6. Do you have a disability which, sometimes or all of the time, prevents you

from boarding, riding or exiting from a TARC bus?

______ Yes ______ No

7.How does your disability prevent you from independently using a TARC bus? Please be specific. (Must be completed) _____________________

_____________________________________________________

8.Do you currently ride a TARC fixed route bus independently?

______	Yes	How often? ______________________
______	No	Date of last bus ride: _____/_____/_____

______ No, but I could ride independently if:

______ I were trained to use the bus

______ I had a ride to the bus stop

______ I don’t have to use more than one bus

______ Other

Section 1 - Continued

9. Have you ever received orientation and mobility training?

______ Yes, If yes, where? ____________________________ Date __________

10. Have you ever received travel training?

______ Yes, If yes, where? ____________________________ Date __________

11.No, If no, do you think you would like to participate in orientation & mobility or travel training?

______ Yes	______ No
12. Is your disability temporary?
_____ No	_____ Don’t know	_____ Yes, I expect it to last ____ months

13.Does your disability change from time to time, preventing you from indepen- dently traveling to and from the bus stop sometimes?

______ Yes, I have some good days and some bad days.

______ No, it’s usually the same all the time.

14. How would you describe the terrain from where you live to the nearest bus stop? (example: steep hills, flat, long gradual hill, etc.) _____ Don’t know

_____________________________________________________________________

15.Are there continuous sidewalks between your house and the nearest bus stop?

______ Yes

______ No

_____ Don’t know

16. How many blocks are there from your residence to the nearest bus stop?

____less than 1 ____1-2 ____2-3 ____3-4 ____more than 4 ____ don’t know

17. Can you cross streets without help?

______ Yes ______ No ______ Sometimes

If no or sometimes, please explain ________________________________________

_________________________________________________________________

Section 1 - Continued

18. Can you cross at streets with very little traffic, stop signs or no traffic control?

______ Yes ______ No ______ Sometimes

If no or sometimes, please explain ________________________________________

_________________________________________________________________

19. Can you cross at traffic lights?

______ Yes ______ No ______ Sometimes

If no or sometimes, please explain ________________________

_________________________________________________________________

20. Can you cross at busy intersections?

______ Yes ______ No ______ Sometimes

If no or sometimes, please explain _____________________________

______________________________________________________

21.Please add any additional information to explain why you cannot ride fixed-route buses.

_____________________________________________________________________

APPLICANT HEALTH INfORmATION

22.General medical Condition

_____ Uncontrolled Diabetes

_____ End Stage Renal Disease

Dialysis? Yes ____ No ____ Days: M T W Th F Sat

_____ Cancer - Being treated until ____________

_____ Other______________________________

How does this condition affect your ability to ride the city bus?

_____________________________________________________________

23. Bone or Joint Conditions
_____ Osteoarthritis	_____ Osteoporosis
_____ Rheumatoid Arthritis	_____ Broken Bone-Date: _______

_____ Amputation -Specify________________

Use of Prosthesis ___Yes ___No

_____ Other______________________________________________

How does this condition affect your ability to ride the city bus?

_____________________________________________________________

24. Brain / Nerve / muscle Conditions
_____ Cerebral Palsy	_____ Dementia	_____ Brain Injury
_____ Multiple Sclerosis	_____ Parkinson’s	_____ Post Polio
_____ Muscular Dystrophy	_____ Quadriplegia	_____ Paraplegia

_____ Stroke
When________________	Which side affected?__________________
_____ Epilepsy
Type___________________	How many per Month?______________

Date of Last Seizure?_____________________

_____ Other: _____________________________________________________

How does this condition affect your ability to ride the city bus?

____________________________________________________________________

25. Heart / Circulatory Conditions

_____ Heart Disease _____ Uncontrolled High Blood Pressure

_____ Leg Edema _____ Advanced Peripheral Vascular Disease

_____ Congestive Heart Failure

_____ Other:______________________________________________________

How does this condition affect your ability to ride the city bus?

____________________________________________________________________

26. Lung Conditions

_____ Chronic Obstructive Pulmonary Disease – Type_____________________

_____ Lung Cancer	_____ Cystic Fibrosis
_____ Asthma

_____ Other: _____________________________________________________

How does this condition affect your ability to ride the city bus?

____________________________________________________________________

27. Vision / Hearing / Speech Conditions
____ Macular Degeneration	____ Retinitis Pigmentosa	____ Cataracts
____ Diabetic Retinopathy	____ Glaucoma	____ Partial Hearing
____ Retinopathy of Prematurity	____ Night Blindness	____ Deaf

____ Other:_____________________________________________________

Best Corrected Vision	Right Eye: 20/____	Left Eye: 20/____
Visual Field Deficit	Right Eye:_______	Left Eye: _______

How does this condition affect your ability to ride the city bus?

____________________________________________________________________

28. Developmental / mental Conditions

_____ Autism	_____ Thought Disorder
_____ Psychosis	_____ Mood/Anxiety Disorder
_____ Developmental Disability ____Mild ____Moderate ____Severe
_____ Mental Retardation	____ Moderate ____ Severe____ Profound
_____ Cognitive Deficits	____ Mild ____ Moderate ____ Severe

How does this condition affect your ability to ride the city bus?

_______________________________________________________

29. Is your health condition temporary?

_____ Yes - How long do you expect it to last?

___Months ___Years

_____ No - How long have you had this condition?

___Since Birth ____Months___Years

_____ I don’t know

30. Does your condition change from time to time in ways that affect your

ability to use the city bus? _____ Yes

_____ No

Describe ____________________________________________________________

____________________________________________________________________

31.If weather conditions such as heat, cold, snow, etc. affect your ability to travel independently, please explain.

____________________________________________________________________

SECTION 2: APPLICANT INFORMATION

TO BE COmPLETED ONLY BY INDIVIDUALS WITH A mOBILITY DISABILITY

PLEASE PRINT

1. How far can you walk independently with short rest breaks?

____ Less than 1 block	____ 1 block	___ 2 blocks
____ 3 blocks	____More than 3 blocks

2. How far can you propel your wheelchair/scooter?

____ Does not apply

____1 block

____ 2 blocks ____3 or more blocks

3. How many minutes can you wait at a bus stop if:

_______Standing?	_____	Bench is provided?
_______With mobility aid?	_____	Don’t know

4.Can you pull the cord, push the bell strip or ask the driver to let you off the bus?

______ Yes

______ No

5.Are you able to keep your balance while seated on a moving bus?

______ Yes ______ No

If no, explain _____________________________

6.Are you able to keep your balance while standing on a moving bus?

______ Yes ______ No

If no, explain ______________________________

SECTION 3: APPLICANT INFORMATION

TO BE ANSWERED BY INDIVIDUALS WITH COGNITIVE OR mENTAL

DISABILITIES, OR BY SOmEONE ASSISTING THE APPLICANT

PLEASE PRINT

1. Are you able to use a telephone? Do you carry a cell phone?

______ Yes

______ No

______ Yes

______ No

2. Can you communicate address, destination and telephone # upon request?

______ Yes

______ No

______ Sometimes

3. Are you able to ask for, understand and follow directions?

______ Yes

______ No

______ Sometimes

4. Can you recognize your destination or landmark near your destination?

______ Yes

______ No

______ Sometimes

5. How do you know when/where to get off the bus? Check all that apply.

______ I ask the driver to announce my stop.

______ I ask another passenger to help me.

______ I can see my stop from inside the bus.

______ Other, please explain

_____________________________________________________________________

6. Can you deal with unexpected situations or bus detours?

______ Yes

______ No

______ Sometimes

7.What would you do if you got lost? Explain

_____________________________________________________________________

Section 3 - Continued

8. Can you wait 15 minutes at a bus stop?

______ Yes

______ No

If no, explain _____________________________

9. If necessary, can you transfer to a second bus to complete your trip?

______ Yes ______ No If no, explain _______________________________

____________________________________________________________________

10. Which of the following are you able to do? Check Yes or No
Can you calculate the correct fare?	____Yes	____ No
Can you put the fare in the box?	____Yes	____ No
Can you cross the street when you get off the bus?	____Yes	____ No
Can you follow instructions in an emergency?	____Yes	____ No
Can you reach your destination when you get off the bus?	____Yes	____ No
Are you able to identify the correct bus stop?	____Yes	____ No
Are you able to identify the correct bus?	____Yes	____ No
Can you travel only if another person accompanies you?	____Yes	____ No
Can you ask for and follow written or oral information,
such as bus schedules (including TTY, tape, voice)?	____Yes ____ No

SECTION 4: APPLICANT INFORMATION

TO BE COmPLETED ONLY BY INDIVIDUALS WITH VISION DISABILITY

	PLEASE PRINT
1. my vision is worse during these conditions:
_____bright sunlight	_____ dimly lit or shaded places
_____nighttime	_____ I have no vision

_____remains the same in different lighting conditions

_____other, please explain ____________________________________________

__________________________________________________________________

2.my eye condition is considered to be:

_____stable

_____degenerative, please explain _____________________________________

____________________________________________________________

_____varies, please explain ___________________________________________

____________________________________________________________

Section 4 - Continued

3.I use the following mobility aids when I walk outdoors: Check all that apply

_____human guide

_____white cane

_____dog guide

_____optical devices (telescope, light, special glasses, etc.)

_____other _______________________________________________________

4.I am able to locate steps:

______ Yes ______No ______Sometimes

If no or sometimes, please explain ________________________________________

_________________________________________________________________

5. I can find my destination without assistance.

______ Yes ______ No ______ Sometimes

If no or sometimes, please explain ________________________________________

_________________________________________________________________

6.Can you walk outdoors alone?

______ If yes, please answer the following:

To places within your neighborhood	_____ Yes	____	No
To places farther away	_____ Yes	____	No

______ If no, please check all that apply.

______ I have never been taught

______ Enviromental barriers prevent me (example: no sidewalk, etc.)

______ Other, please explain _______________________________________

_______________________________________________________________

SECTION 5: APPLICANT SIGNATURE

I certify that the information on this application is true and correct to the best of my knowledge. I understand that falsification of information will result in a denial of TARC3 Transportation service. I understand the information provided on this applica- tion may be disclosed to others as necessary to provide the services I have requested and as may otherwise be required by law. I give consent for TARC to contact the per- son who has completed the TARC3 Medical Form attached to this application, in order to confirm the information included on this application. I understand that if I refuse to undergo an independent in-person evaluation screening and/or functional assessment it will be conclusively determined that I am withdrawing my application for TARC3 Transportation service.

Signature___________________________________ Date______________________

(or mark)

If COmPLETED BY SOmEONE OTHER THAN APPLICANT:

I certify that the information provided is true and correct based upon my own knowl- edge of the applicant’s functional abilities.

Print Name ___________________________________________________________

Relationship to Applicant_________________________________________________

Agency (if applicable) __________________________________________________

Daytime Phone __________________________ Evening Phone _______________

Signature_____________________________ Date __________

Please return completed application packet to:

TARC3 Transportation

1000 West Broadway

Louisville, KY 40203

Rev. 1108	15

TARC3 Medical Form

(General Medical or Physical Disability)

Name of Applicant ________________________________________________

Address ______________________________________Apt #______________

City _____________________Zip Code___________ Phone_______________

MEDICAL RELEASE

I (applicant signature)____________________________do hereby authorize my

physician, medical clinic, or health care provider, to release to Transit Authority of River City any medical information related to my condition that will assist in the determination of my ability to ride the city bus.

May Be Completed Only by a Certified Health Care Professional

This medical information is being requested by TARC to determine the applicant’s ability to safely and effectively use the city bus system.

Applicant has been patient of mine since: ____/____/____

Date of applicant’s last physical evaluation: ____/____/____

1.Please indicate the nature of your patient’s condition or disability. (Check all that apply)

Diabetes

End-Stage Renal Disease Undergoing Cancer treatment

Arthritis: Please specify type and area/s___________________________

______________________________________________________________

Amputation: Please specify extremity and/or use of prosthesis__________

______________________________________________________________

Neurological Condition: Cognitive Deficits? ____Mild ____Moderate ___Severe Epilepsy

Neuromuscular Condition Muscular Condition

Pulmonary Disease: If on oxygen, how many liters per min? _________________

Cardiac Disease

Kidney Disease: Dialysis? ____Yes ____No

Eye Condition

Seizure Disorder Type(s) of seizures? ___________________________________

______________________________________________________________________

How often do the seizures occur? ___________________________________________

After a seizure, how long does it take before the applicant is able to function safely?

______________________________________________________________________

Are the seizures preceded by an aura? What triggers the applicant’s seizure?

Yes	____________________________________
No	____________________________________

If the applicant is taking medication for the seizures, is he/she able to function safely and effectively in the community?

Yes

Please explain how the condtion/s would prevent the applicant from being able to safely and effectively use regular city buses.

_________________________________________________________________________

If there are other conditions that you feel would prevent the applicant from being able to

safely and effectively use regular city buses, please list and explain here:

_________________________________________________________________________

2. Is this condition/s temporary? ___Yes ___No

If temporary, what is the expected duration? ______________________________________

3.Are there any environmental conditions that would exacerbate the applicant’s condition/s? Please list:

_________________________________________________________________________

4.Do you feel the applicant could be trained to independently use regular city buses safely and effectively?

___Yes ___No

5.How far do you feel the applicant could independently propel a wheelchair or ambulate with or without a mobility aid, and without lengthy rest breaks?

No functional mobility

______Blocks (500’ = 1 block) Greater than ½ mile

6. Do you feel the applicant could stand for 10 minutes or sit in a wheelchair for 10 minutes

at a bus stop to wait for a regular city bus? ___ Yes ___ No

7.Please provide any additional information that you feel relevant to the applicant’s ability to safely and effectively use regular city buses: _____________________________________

_________________________________________________________________________

8.TARC3 (paratransit) drivers assist individuals from the door of their origin to the van, and from the van to the door of their destination. Does the applicant require additional assistance

from a PCA? ___Yes ___No if “yes”, please describe the type of assistance needed:

_________________________________________________________________________

Name of Medical Professional Completing this Form:

Print Name: _____________________________________________

Professional Title: ____________________________________________________

Area of Professional Specialization: ______________________________________

“I certify that the information contained herein is true and correct to the best of

my knowledge and ability.”

Signature______________________________________Date_________________

Professional License, Registration or Certification Number:

#_____________________ State____________________

Clinic or Agency___________________________________________________

Address__________________________________________Suite____________

City________________________________State____________Zip__________

Phone (____) _________________

Please return this medical verification to the applicant.

Thank you

(revised 6/2/09)

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