Access Johnson County Public Transit ADA Paratransit Eligibility Application
The Purpose of this application is to provide an opportunity for you to describe how your disability prevents you from riding the Zip Line – fixed route system. This includes any environmental (weather, ice, etc.) as well as physical barriers (Terrain, steps, etc.) that prevent you from riding the fixed route. Information contained in this application will be kept confidential and shared with the professionals involved in the evaluation of your eligibility for ACCESS or others only if disclosure is required by law.
Please complete the application as thoroughly as possible and to the best of your ability. If you have difficulty answering any questions on the application or if you need assistance completing this form. Please call ACCESS at (317) 738-5523. We cannot begin processing eh application until it is complete. If a question does not apply to you, please write “Not Applicable” or “NA”.
There are two sections to this application: Applicant’s Questionnaire – to be filled out by the applicant or by someone on the applicant’s behalf. Medical Professional’s Questionnaire – to be filled out by a medical professional familiar with the applicant’s abilities.
The application will not be considered complete by ACCESS staff until both Questionnaires are completed in full* and delivered or mailed to:
Access Johnson County Public Transit PO Box 216 3500 N Morton Street Franklin, IN 46131
**Incomplete Applications: Under conditions where the applicant satisfactorily shows the Medical Professional’s Questionnaire cannot be completed in a reasonable time due to protracted appointment dates or other causes beyond control of the applicant, ACCESS staff will make a temporary eligibility determination based only on the Applicant’s Questionnaire. If granted, it will extend until 21 days after the provided appointment date. If not granted, it will be reconsidered as a new application once the completed Questionnaire is received.
Access Johnson County Public Transit Applicant’s Questionnaire:
Name ____________________________________________ Date of birth: __________ Address _____________________________________________________ Apt. _______ City __________________________ State ________ Zip Code _____________________ Home Phone _____________ Cell Phone ______________ Work Phone ______________ Email Address ______________________________________________________________ Emergency Contact _______________________ Relationship __________ Phone _________ If the applicant is being assisted in this section, the assistant should complete this part below: Name ____________________________________ Day time Phone _____________________ Address ______________________________________________________________________ Relationship to Applicant _______________________________________________________ Email Address ________________________________________________________________ To whom should we communicate with regarding eligibility, etc.? Please circle one: Applicant Assistant Other If “Other”, please fill in below Name ____________________________________ Day time Phone _____________________ Address ______________________________________________________________________ Relationship to Applicant _______________________________________________________ Email Address ________________________________________________________________ Will you need future materials in an alternative format? If yes, please circle one: Large Print Email Compact Disc
INFORMATION ABOUT YOUR DISABILITY AND MOBILITY EQUIPMENT What is the disability that prevents you from using the ACCESS fixed route system? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
My disability is permanent
My disability is temporary until ___/___ (month/year)
My disability changes from day to day: Explain ______________________________
What mobility aid do you use? (check all that apply)
Manual Wheelchair
Motorized Wheelchair
Service Animal
Prosthesis
White Cane
Crutches
Cane
Portable Oxygen
Walker
Braces
Other ____________________
Wheelchair users: _____ Length _____ Width ______ Weight YOU’RE USE OF ACCESS FIXED ROUTE SYSTEM (check all that apply)
I use the US 31 Zip Line (fixed route service) or Connectors (flexible fixed route) frequently.
I have never attempted to ride the fixed route buses.
I believe I could learn to ride the fixed route bus, if someone would teach me.
I can us the fixed route and flexible fixed service and get to bus stops if the conditions are right.
I use fixed route and flexible fixed service now, I will need the assistance of another person (sometimes/always)
I am not sure if I can ride the fixed route or flexible fixed route buses.
It is impossible for me to use the fixed route or flexible fixed route buses to some destinations
Would you like travel training to learn to ride the fixed route or flexible fixed route bus?
DISABILITY EFFECT
I have difficulty understanding or remembering the schedule on my way to and from the bus.
I have difficulty or cannot climb stairs and can only board a bus with a lift/ramp.
I have a visual disability which prevents me from getting to and from the bus.
My medical condition is such that I can ride the fixed route bus only when I am feeling well.
My disability prevents me from getting to and from the bus stop.
YOUR ABILITY TO USE THE ACCESS ZIP LINE FIXED OR FLEXIBLE FIXED ROUTE SYSTEM
List things about riding a fixed route bus that is difficult for you?
Can you cross the street by yourself? (Yes / No / Sometimes) Explain ________
If you have used the fixed or flexible fixed route system, when did you use it last? ________ What Route? ________
What is the closest bus stop to your home? __________________________
Can you get to this stop by yourself? (Yes / No / Sometimes) Explain: ________
Does the weather affect your ability to use the fixed route or flexible fixed route system? (Yes / No ) Explain: ____________________________________________ VISUAL IMPAIRMENT
Please fill out this section if you have a visual impairment. Name of Eye Disease / Condition: __________________________________________ My vision is worse during these conditions:
Bright Sunlight
Dimly lit or shaded places
Night time
I have not vision at all
My eye condition is: Stable Degenerative Other _________________
I can see steps and curbs
I can see the route numbers on the bus from the bus stop
I can find the bus stop without assistance.
ADDITIONAL INFORMATION: Please use this space to tell us anything else your travel challengers and your ability to use the ACCESS fixed and flexible fixed route system: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
INFORMATION RELEASE FORM In order for Access Johnson County Public Transit to evaluate your part of the application, it may be necessary to contact someone who is familiar with your abilities. This does not need to be the person that fills out Medical Professional’s Questionnaire. This can be a Case Manager, a Social Worker, or an employer, for example: Please complete the following information and authorization form.
Health Care Professional (physicians, nurse, physical therapist, rehabilitation specialist, etc.)
Case Manager
Social Worker
Other (please explain) ______________________________________________
The following professional (please check one above) is familiar with my disability and functional abilities and is authorized to provide the required information to Access Johnson County Public Transit. Name: _______________________________________________________________________________________ First MI Last Address ______________________________________________________________________________________ _____________________________________________________________________________________________ City State Zip Code Phone ___________________________________________ Fax _________________________________________
I hereby certify that the information given in this Questionnaire is correct. I understand that if my application is not found to be eligible, that I may appeal such determination within 60 calendar days and that I will be advised of the procedures for such an appeal. I hereby authorize AJCPT to contact the professional or agency listed above to verify functional abilities.
Applicant’s Signature ____________________________________________ Date___________________ Witness (if assisted) ____________________________________________ Date ____________________
Medical Professional’s Questionnaire
The Questionnaire is to be filled out by a medical professional who is not only familiar with the applicant’s diagnosis, but who is also familiar with his/her mobility. Access Johnson County Public Transit policy requires this to be a medical professional (Physician, licensed Nurse, Physical Therapist, Rehabilitation Specials, licensed Psychologist, etc.). If you have any questions regarding what professionals will be accepted please call AJCPT at (317) 738-5523.
GUIDELINES FOR PROFESSIONAL REPORT TO ACCESS Your patient/client has requested eligibility for ADA transportation service. Because of your professional relationship with this applicant you are uniquely qualified to help clarify his or her functional abilities and limitations. The following are guidelines for using AJCPT. This guidelines may help you understand the information we need to determine the applicant’s eligibility for ACCESS.
ADA paratransit service provides curb-to-curb transportation on a shared-ride basis to eligible individuals whose disability prevents them from using the fixed –route bus transportation at all, or under certain circumstances.
The basis for ADA eligibility is the American with Disabilities Act, Eligibility is based on:
Functional ability to independently perform the tasks necessary for bus use including getting to and from the bus stop, getting on the bus, riding the bus and understanding how to navigate the system in a variety of environments. A diagnosis by itself does not qualify an individual for ACCESS ADA Service.
Whether the disability prevents the individual from performing these tasks (as opposed to the task being more inconvenient or difficult).
Whether the individual can perform these tasks all the time, only under some circumstances, or never. An example of “some circumstances”: the individual can use the fixed-route if it is two level blocks or less to the bus stop and no snow or ice are present.
Information we need from you: You may expand in an s much detail as you can provide how these individuals physical sensory, cognitive or emotional problems may impact his/her/ability to travel on a bus. Please relate your comments to the specific tasks necessary to get to and from a bus stop, board, ride and navigate the ACCESS fixed route system. If you have any questions regarding ADA eligibility or this Questionnaire, contact the Director of Transportation at ACCESS (317) 738-5523. Thank you for your cooperation. Please email or mail the application to: becky.allen@gatewayarc.com Access Johnson County Public Transit PO Box 216 Franklin, IN 46131 PROFESSIONAL VERIFICATION
Applicant’s Name: ______________________________________Date of Birth: ______
Relationship with the applicant: ___________________________ No. of years: ______
Date of last face-to-face contact (by you or your agency)? _______________________
Primary Diagnosis: ______________________________________ No. of years _____
Current Treatment: ______________________________________________________
Medication’s effect on the individual’s ability to travel independently: ________________ Functional Abilities:
Applicant can walk. Describe walking ability (distance, speed) under good, level conditions: ______________________________________________________
Urban conditions (weather, terrain, street width/conditions) where applicant could not walk: ________________________________________________________
Can the walking applicant: (check all that apply)
__ Navigate around large objects __ Negotiate gravel surfaces __ Navigate around small objects __ Negotiate loose dirt/sand surface __ Locate curbs __ Walk up a 16’ reasonable slope __ Step up a 6” curb ` __ Walk up a 30’ reasonable slope __ Step down a 6” curb __ Cross streets at a crosswalk __ Negotiate sidewalks in good condition __ Locate a safe place to cross __ Negotiate on broken pavement __ Activate a “walk” light __ Negotiate on uneven/grassy surfaces __ Wait without a bench for 20 min. Mobility aid(s) used by the applicant: Type? ______________________ No. of years ________ Describe travel mobility (distance, speed) under good, level conditions: _____________ ____________________________________________________________________________ Urban conditions 9weather, terrain, street width/condition) where mobility fails: _____________ ____________________________________________________________________________ Can the mobility-aided applicant: __Negotiate on to a curb lift ramp __ Place fare in firebox __ Handle fare tickets Conditions: Are any of the following conditions affected by the applicant’s disability? (check all that apply) __ Orientation __ Gait or balance __ Sensitivity to cold weather __ Problem solve __ Sense of Time __ Sensitivity to hot weather __ Short term memory __ Judgment __ Inappropriate social behavior __ Long term memory __ Communication __ Anxiety level __ Other (please explain) _______________________________________________________ *Please describe any inappropriate social behavior ___________________________________ Are any of the following conditions observed from the applicant? (check all that apply) __ High day-day variability in disability __ Visual hallucination __ Inconsistent performance __ Seizures: Type: __________________ __ Auditory hallucinations __ medication controlled? ______ Please explain any checked conditions: ___________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Training: Would travel training for the fixed route system be appropriate for the applicant? ____________ Would training toots help with fixed route travel? (Ex. Memory cards, written route directions, photos, etc.) __________________________________________________________________ Is the goal of traveling independently on the fixed route system within the context of treatment? __ Additional Info: Any additional appropriate information about the applicant: _____________________________ ____________________________________________________________________________ ____________________________________________________________________________ I certify that this information is true and correct to the best of my knowledge. Signature _____________________________________________________ Date __________ Print Name ______________________________________ Licensed Title ________________ Agency ______________________________________________________________________ Address _____________________________________________________________________ Email address ________________________________________________________________ Phone number _______________________________________