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PLEASE CALL TO GET THESE FORMS ADA DEMAND
RESPONSE Service
Application Mailing Address: SRTA 700 Pleasant Street, 1st Floor New Bedford, MA 02740 If you have any questions please contact us at (508)
997-6767, or at our email address: srtaservice@aol.com. |
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INFORMATION OBTAINED IN THIS CERTIFICATION PROCESS WILL
ONLY BE USED BY THE SOUTHEASTERN REGIONAL TRANSIT AUTHORITY FOR THE PROVISION
OF TRANSPORTATION SERVICES. INFORMATION WILL ONLY BE SHARED WITH OTHER
TRANSIT PROVIDERS TO FACILITATE TRAVEL IN THOSE AREAS. THE INFORMATION WILL
NOT BE PROVIDED TO ANY OTHER PERSON OR AGENCY. (Return completed application to: SRTA, 700 Pleasant Street, Suite #1, New Bedford, MA
02740) - - - PLEASE PRINT - -
- 1. Name:
__________________________________________________________________________________
(last) (first) (middle initial) 2. Address
________________________________________________________________________________
(street) (apt. #) _____________________________________________________________________________________________
(city/town) (state) (zip) 3. Mailing Address (If Different) ____________________________________________________________________________________________
(street) (p.o. box #) (city/town) (state) (zip) 4. Telephone Number: (home)
_____________________ (work) ____________________________ 5. Date of Birth: _________________________ Soc. Sec.
#: ()not required)_____________________ 6. How does this disability prevent you from using
fixed route service? Please explain completely. Use an additional sheet if
needed. ____________________________________________________________________________________________
_______________________________________________________
____________________________________ Is this condition temporary? ______ If Yes, expected
length: ________ 7. Are there any other effects of your disability of
which we need to be aware? __________________________________________________________________________________________
8. Do you have an email address:? ________ (Yes/No) If so what is it?_________________________________ |
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(2/15/05) |
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THE FOLLOWING INFORMATION WILL BE USED TO ENSURE THAT
THE APPROPRIATE SERVICE IS PROVIDED TO YOU AND THAT AN ACCURATE ANALYSIS OF
YOUR TRIP REQUESTS CAN BE MADE BY THE SOUTHEASTERN REGIONAL TRANSIT
AUTHORITY. 9. Do you use any of the following aids to mobility? (Check
all that apply) Manual wheelchair ____ Power scooter ____ Powered chair
____ Cane _____ Walker _____ Crutches _____ Braces _____
Aide dog _____ 10. Please answer the following questions: Can you travel 200 feet without the assistance of another
person? Yes _____ No _____ Sometimes (explain)
_________________________ Can you travel 1/4 of a mile without the assistance of
another person? Yes _____ No _____ Sometimes
(explain)_________________________ Can you travel 3/4 of a mile without assistance of
another person? Yes _____ No _____ Sometimes
(explain)_________________________ Can you climb three (3) 12 inch steps without
assistance? Yes _____ No _____ Sometimes
(explain)_________________________ Can you use fixed route buses if they have wheelchair
lifts / kneeling steps? Yes _____ No _____ Sometimes
(explain)_________________________ Can you wait outside without support for ten minutes? Yes _____ No _____ Sometimes
(explain)_________________________ Can you deal with unexpected situations or routines? Yes _____ No _____ Sometimes
(explain)_________________________ Can you follow directions or give requested
information? Yes _____ No _____ Sometimes
(explain)_________________________ Can you travel through crowded terminals? Yes _____ No _____ Sometimes
(explain)________________________ I HEREBY CERTIFY THAT THE INFORMATION GIVEN ABOVE IS
CORRECT. Signed ____________________________________ Date
___/___/___ |
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IN ORDER TO ALLOW SRTA TO EVALUATE YOUR REQUEST, PLEASE
CONTACT A PHYSICIAN, HEALTH CARE PROFESSIONAL OR OTHER PROFESSIONAL TO
CONFIRM THE INFORMATION YOU HAVE PROVIDED. PLEASE HAVE THE FOLLOWING
INFORMATION PROVIDED TO THE AUTHORITY. ALL QUESTIONS MUST BE ANSWERED BEFORE
A DETERMINATION CAN BE MADE. THE ATTACHED INFORMATION HAS BEEN SUBMITTED TO SRTA BY
THE APPLICANT. SRTA ASKS THAT YOU PROVIDE INFORMATION REGARDING HIS/HER
DISABILITY AND ITS IMPACT UPON HIS/HER ABILITY TO UTILIZE OUR TRANSIT
SERVICES. FEDERAL LAW REQUIRES THAT SRTA PROVIDE PARATRANSIT SERVICES TO
PERSONS WHO CANNOT UTILIZE AVAILABLE FIXED ROUTE SERVICES. A PERSON MUST HAVE
AN ACTUAL PHYSICAL OR MENTAL FUNCTIONAL LIMITATION THAT DOES NOT ALLOW THEM
TO USE REGULAR ACCESSIBLE PUBLIC TRANSPORTATION. A MEDICAL DIAGNOSIS OF AN
ILLNESS OR MEDICAL CONDITION DOES NOT AUTOMATICALLY MAKE THE APPLICANT
ELIGIBLE FOR SERVICE. THE INFORMATION THAT YOU PROVIDE WILL ALLOW US TO MAKE
AN APPROPRIATE EVALUATION OF THIS REQUEST AND ITS APPLICATION TO SPECIFIC TRIP
REQUESTS. THANK YOU FOR YOUR COOPERATION IN THIS MATTER. 1. Capacity in which you know the applicant: 2. Condition preventing or limiting the applicant from
using regular fixed route service: (Diagnosis- Certified MUST
complete) 3. Is the condition temporary? Yes / No _____
Expected duration: until __/__/__ 4. If the person has a disability effecting mobility
can the person: Travel 200 feet without assistance? Yes _____ No _____ Travel 1/4 mile without assistance? Yes _____ No _____ Travel 3/4 mile without assistance? Yes _____ No _____ Climb three (3) 12 inch steps without assistance? Yes
_____ No _____ Wait outside without support for 10 minutes? Yes _____
No _____ IF `YES" TO ANY OF THE ABOVE QUESTIONS: Can the applicant use regular fixed route service if that service has
wheelchair lifts or kneeling steps? Yes _____ No _____ |
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5. Does the client require a Personal Care Attendant
when traveling? Yes / No (circle one) 6. Does the client use any of the following aids to
mobility? (Check all that apply) Manual wheelchair ____ Power scooter ____ Powered chair
____ Cane ____ Walker ____ Crutches ____ Braces ____ Aide
dog ____ 7. Is the person effected by certain weather / climate
conditions or geographical features which prevents him/her from using fixed
route service? WEATHER: Cold / Ice ________ Heat / Humidity ________ PHYSICAL TERRAIN: (SPECIFY)
____________________________________ 8. If the person has a visual impairment: Visual acuity with best correction: Right Eye __________ Left Eye __________ Both Eyes
___________ Visual fields: Right Eye __________ Left Eye __________ Both Eyes
___________ 9. If the person has a cognitive disability: Is the
person able to: Give addresses and telephone numbers upon request? Yes _____ No _____ Recognize a destination or landmark? Yes _____ No _____ Deal with unexpected situations or unexpected change in
routine? Yes _____ No _____ Ask for, understand and follow directions? Yes _____ No _____ Safely and effectively travel through crowded and/or
complex facilities? Yes _____ No _____ 10. Are there any other problems of which SRTA should
be aware? Please describe _____________________________________________________________________________________________
Certifier's Name (Please Print):
_______________________________________________________ Office Address:
_________________________________________________________________________ Office Phone Number:
__________________________________________________________________ Signature: ____________________________________ Title:
______________________________________ (NOTE: FAILURE TO ANSWER THESE QUESTIONS MAY DELAY OR
JEOPARDIZE THE CERTIFICATION FOR SERVICE.) - Office Use Only - Date Received: _________ Certification #: _______
Category: _________ Comments: PM5-ADAPP-2/10/04 |
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