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Home My Public Portal AboutADA Paratransit Application-COR DAVE SNOW Mayor CITY OF RICHMOND GREG STIENS ROSEVIEW TRANSIT Director 401 SOUTH Q STREET, RICHMOND, INDIANA 47374 Public Works PHONE (765) 983-7227 TERRI QUINTER Operations Manager ROSE VIEW TRANSIT PARATRANSIT APPLICATION PART A - FOR THE APPLICANT TO COMPLETE • If you believe that you have a disability that prevents you from using Rose View Transit Fixed Route Service, please complete this application and return it to Rose View Transit. • An in-person evaluation of your inability to use the Rose View Transit Fixed Route Service may be necessary. You may be found eligible for paratransit curb-to-curb service for all of your trips, for some of your trips, or capable of using the Rose View Fixed Route Service. • It is important that all parts of this application be completed. If not, it will be returned to you for completion. All information will be kept confidential. PLEASE PRINT Name, First: _______________________ Last: _______________________ Initial: ________ Title: ❑ Mr. ❑ Mrs. ❑ Ms. ❑ Miss ❑ Other: ________ Are you a? (Circle one) New Applicant Renewal Applicant Date of Birth (month/date/year): ________ / ________ / ________ Address: ___________________________ City: _______________________ Zip: ________ Phone (day): __________________ (evening) __________________ TDD: _______________ Email: _____________________________________________________________________ In case of emergency, notify: Name: ________________________________ Phone: _______________________ Email: ______________________________________________________________________ Address: ___________________________ City: _______________________ Zip: ________ Do you reside with: ❑ Family/Friend ❑ By Yourself ❑ Supported Living ❑ Group Home ❑ Nursing Home ❑ Assisted Living Please indicate the type of alternative format you require for future mailings: ❑None ❑ Large Print ❑ Audio Tape ❑ Braille ❑ another language: ________________________ PART A – FOR THE APPLICANT TO COMPLETE Disability Information A. Please choose the best category that describes how your disability affects your ability to ride the city bus. ❑ I am always able to ride Rose View Fixed Route buses but with some difficulty. ❑ I am unable to ride Rose View Fixed Route buses without the assistance of someone else. ❑ I am unable to get to and from the bus stops. ❑ I am unable to board Rose View Fixed Route buses without the use of a ramp. What is your disabling condition(s)? _________________________________________________________________________ B. Please, explain how your disability prevents you from using the Rose View Fixed Route Service. Be specific. (Attach separate sheets, if necessary.) _________________________________________________________________________ _________________________________________________________________________ C. Does your disability or health condition change from time to time in ways that affect your ability to use Rose View’s regular city bus system? ❑ No ❑ Yes (how?) _________________________________________________________________________ _________________________________________________________________________ D. Do you require an attendant to accompany you when you travel by public transit? ❑ No ❑ Yes (If yes, why?) ___________________________________________________ E. Do you require Door to Door Assistance? (Drivers may provide assistance from your door to the vehicle depending on the level of help you require). ❑ Yes ❑ No (You will have to meet the vehicle at the curb closest to your location.) Mobility Information F. Which of these mobility aids do you use? (If none required, skip to J.) ❑ Manual Wheelchair ❑ Cane ❑ Oxygen Tank ❑ Power Wheelchair ❑ Crutches ❑ White Cane ❑ Power Scooter ❑ Walker ❑ Prosthesis ❑ Leg Brace ❑ Service Animal (type) ____________________ ❑ Other ____________________ G. Is your wheelchair or scooter larger than 30 inches wide by 48 inches long? If so, you may not be able to enter or ride on an accessible paratransit vehicle with it. ❑ Yes (Width) ________ (Length) ________ ❑ No, it is under these sizes. H. Does your wheelchair or scooter (with you in it) weigh more than 800 pounds? If so, you may not be able to enter or ride on an accessible paratransit vehicle with it. ❑ Yes, the combined weight is ________. ❑ No, weight is less than 800 pounds. I. Can you transfer from your wheelchair or scooter to another seat without assistance? ❑ Yes ❑ No J. Using your mobility aid or on your own, how many blocks can you travel? (Imagine a city block to be approximately 500 feet in length.) ❑ 1 to 2 ❑ 3 to 4 ❑ 5 or more ❑ do not know K. How often do you currently ride the Rose View buses? ❑ Daily ❑ Weekly ❑ Monthly ❑ Other: ________ L. How long can you wait outside at a Rose View bus stop? ❑ 5-10 minutes ❑ 10-15 minutes ❑ 15-30 minutes ❑ other Why? _____________________________________________________________ M. What skills do you know that enable you to ride Rose View’s fixed route buses? ❑ To travel to and from bus stops ❑ To cross streets ❑ To ride all or some bus routes ❑ To read bus schedules ❑ Deal with unexpected situations ❑ Read informational signs ❑ Navigate independently ❑ Ask for, understand & follow directions ❑ Other __________________________________________________________________ N. Can you get to and from the closest Rose View bus stop, from your home? ❑ Always ❑ Never ❑ Sometimes ❑ Do not know If never why? ______________________________________________________________ If sometimes why? __________________________________________________________ O. Have you ever been taught how to ride Rose View’s buses or public buses in another city? ❑ Yes ❑ No If yes, when? _______________________By whom? ____________________________ P. Please, tell us anything else about your disability and how it affects your ability to use Rose View buses (attach additional sheets, if required). _________________________________________________________________________ _________________________________________________________________________ In order for Rose View Transit to evaluate your request for paratransit services, it is necessary to contact your medical professional, health care provider to confirm the information you have provided. Please complete and sign the following authorization. I authorize Rose View to contact the medical professional listed below to obtain information regarding my disability and its effect on my ability to get around on my own. I understand that all information will be kept confidential, and only the information required to provide the services will be disclosed to those who perform those services. Name of Medical Professional: _____________________________________________________ Street Address: ________________________________________________________________ City: _______________________________ State: ________________ Zip: _____________ Telephone: (______) _________________________ Applicant’s Name: ______________________________________________________________ (Please print) Applicant’s Signature: ___________________________________________________________ I hereby certify that the information given in this application is correct. I understand that falsification of information may result in denial of service. Applicant’s Signature: ___________________________________ Date: __________________ If you are not the applicant but have completed this application on the applicant’s behalf, you must provide the following information: Your Name: __________________________________________________________________ Address: _____________________________________________________________________ Phone Number: ________________________________________________________________ Relationship to Applicant: ________________________________________________________ Signature: ___________________________________________ Date: __________________ YOU HAVE COMPLETED PART-A Take or mail Part-B of this document to your medical professional. The professional certification (Part-B attached) must be filled out by an appropriate professional. Who Can Certify: If your disability prevents you from using the regular bus system, one of the following professionals, as appropriate to your case, should complete Part-B. If you plan to use another professional not listed below, you must get prior approval from Rose View Transit first. Please understand that Rose View Transit may contact your chosen professional for additional assistance. Physician Physical therapist Special Education Teacher Psychiatrist Social worker O&M Specialist Psychologist Rehabilitation specialist Registered Nurse Occupational therapist Physiatrist Other: _____________________________ (Rose View Approval) PART-B FOR THE PROFESSIONAL TO COMPLETE • Part B must be personally completed by an Accepted Licensed Professional. • Please Write Legibly. Typed applications may not be accepted. Professional: You are being asked by the applicant to provide information regarding his or her ability to use Rose View’s fixed-route transit services. Rose View Transit may provide paratransit services to persons who cannot use the accessible fixed-route transit services. The information you provide will help us evaluate the request and provide appropriate transportation services for the applicant. All information will be kept confidential. To qualify for paratransit services, the applicant must be unable to use Rose View’s accessible fixed route city buses due to the effects of a disability. Your certification should consider only the effects of the applicants’ disability that prevents them from riding Rose View buses. Please note this does not include persons who find it uncomfortable or difficult to ride the bus or get to and from the bus stop. Rose View buses are 100% accessible for individuals with disabilities. Rose View buses are equipped with: • Manual announcements to identify buses, stops, and major landmarks. • Exterior displays to identify buses and their destinations. • Designated seating for passengers with disabilities and seniors. • Lifts that can be deployed over sidewalks for easy no-step boarding. • Wheelchair seating locations and wheelchair securement devices. • Fare boxes that accept passes instead of money. • Drivers, who will assist with boarding, exiting, or giving directions. PART B – REQUEST FOR PROFESSIONAL CERTIFICATION Please answer ALL of the following about the functional ability of the applicant. Name of Applicant: ____________________________________________________________ Capacity in which you know the applicant: __________________________________________ Primary Condition Causing Disability: (Please describe; Attach additional documents as necessary) ____________________________________________________________________________ Severity: ____ Mild ____ Moderate ____ Severe ____ Profound Secondary Condition Causing Disability: (Please Describe) ____________________________________________________________________________ Severity: ____ Mild ____ Moderate ____ Severe ____ Profound Is the condition temporary? ____ No ____ Yes (expected duration) 1. How does this person’s disability cause a functional limitation(s) that prevents his or her ability to ride the city fixed bus service? _________________________________________________________________________ _________________________________________________________________________ 2. If the person’s ability to get around on his/her own varies in degree at different times, please explain. Please be specific. _________________________________________________________________________ _________________________________________________________________________ 3. Assuming the length of a city block is 500 feet, how many city blocks can this person walk or wheel? ❑ 1 to 2 ❑ 3 to 4 ❑ 5 or more ❑ other: _____________ 4. What is this person’s ability to deal with unexpected situations one may encounter when riding the city fixed route service? _________________________________________________________________________ _________________________________________________________________________ PART B – REQUEST FOR PROFESSIONAL CERTIFICATION 5. What is this person’s ability to recognize their destination(s) and leave the bus? ________________________________________________________________________ ________________________________________________________________________ 6. What is this person’s ability to understand directions needed to ride the bus? ________________________________________________________________________ ________________________________________________________________________ 7. Does this applicant require the assistance of a competent aid to travel with him or her? ❑ *Yes (always) ❑ Yes (sometimes) ❑ No If yes, why? ______________________________________________________________ * If “Yes – always, you are requiring this applicant to travel with an aid at all times and requiring that Rose View Transit must not schedule independent trips for this applicant. Acquiring PCA’s are the responsibility of the applicant. 8. Can this person cross streets at pedestrian cross walks without assistance? ❑ Yes ❑ No (If no, why?) _______________________________________________ 9. Could this person benefit from Travel Training (learning how to ride the bus)? ❑ No (If no, why?) ________________________________________________________ ❑ Yes (choose type of training below) ❑ Destination Training: One-to-one instruction on how to ride the city bus to and from specific destinations. ❑ General Training: Applicants learn how to read bus schedules and navigate Rose View’s fixed bus routes. ❑ Mobility Practice: Applicants practice boarding and exiting Rose View buses. PART B – REQUEST FOR PROFESSIONAL CERTIFICATION Is (are) there any other effect(s) of the applicant’s disability that Rose View Transit should be aware of? If so, please provide the information here. Please print (attach additional sheets, if required). ____________________________________________________________________________ ____________________________________________________________________________ I have reviewed the information in this section (Part-B) and hereby certify that it is true and correct to the best of my knowledge. I understand that knowingly providing false information on this application to obtain, aid, or facilitate another in obtaining complementary paratransit service violates United States Code Title 18. Penalties are fines and imprisonment. Print Name and Title: ___________________________________________________________ Signature: ______________________________________ Date: ______________________ Clinic/Agency: _______________________________ Phone: ________________________ Address: _______________________________ City: ________________ Zip: ________ Professional License, Registration or Certification #: _________________________________ Completion of this application by any other professional will not be accepted without prior authorization of Rose View Transit. Profession (check one): ❑ Physician ❑ Physical therapist ❑ Special Education Teacher ❑ Psychiatrist ❑ Social worker ❑ O&M Specialist ❑ Psychologist ❑ Rehabilitation specialist ❑ Registered Nurse ❑ Physiatrist ❑ Occupational therapist ❑ Other (with Rose View Approval) Please Return Completed Applications to . . . Rose View Transit 401 South “Q” Street Richmond, IN 47374 Fax: (765) 983-7305