• ACCESS GSO Eligibility Questionnaire

    ACCESS GSO Eligibility Questionnaire

    Part A

  • The Access GSO Application has two different forms- this one, and the ACCESS GSO Medical Form (Part B). Both forms must be completed and received by GTA.

    (1)  ACCESS GSO Eligibility Questionnaire Form (Part A) and (2)  ACCESS GSO Medical Form (Part B)

    STEP 1 – Complete this ACCESS GSO Eligibility Questionnaire form.

    The ACCESS GSO Eligibility Questionnaire Form should be filled out by the applicant or the applicant’s representative.  The form must be completely filled out and signed by the applicant, or if the applicant is less than 18 years of age, the applicant’s guardian and anyone who assisted the applicant in completing the form. Submitting this form will take you directly to the form in Step 2.     

    STEP 2 - Complete ACCESS GSO Medical Form Section A: Authorization to Release Information. Designate a health care professional familiar with the applicant’s disability.  Health care professionals may include, but are not limited to, the following professionals:

    Family Physician  Independent Specialist  Ophthalmologist
    Physical Therapist Rehabilitation Specialist Psychiatrist
    Occupational Therapist Licensed Social Worker  Psychologist
    Orientation & Mobility Registered Nurse Case Manager
    Therapist    

    When you submit the ACCESS GSO Medical Form Section A, you will receive a PDF of Section B: Professional Verification to deliver or send to your selected professional. Your selected professional must complete this form and return it either directly to you, or to the GTA Office at: City of Greensboro, Public Transportation Division, P. O. Box 3136, Greensboro, NC  27402.

    STEP 3 - Once you have the completed ACCESS GSO Eligibility Questionnaire Form and ACCESS GSO Medical Form Section A, and insured either you or GTA’s receipt of the completed Section B Professional Verification Form,

    If you have questions about the application or need assistance in completing the two forms, please email accessgsoeligibility@greensboro-nc.gov or call (336) 373-2166.

     

  • Part 1. General Information

  • Contact Phone Type (select at least one)*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Are you eligible for Medicaid Benefits?*

  • Part 2. Disability and Mobility Information

  • 2. Is your disability described above…. (check only one)*

  • If temporary, how long do you expect it to last? * months.

  • 3. Does your disability change from day-to-day under certain circumstances?*
  • 4. Which of the follow mobility aids or equipment do you use when traveling to destinations outside of your home?*

  • IMPORTANT NOTE   


    An assessment of your mobility aid will be conducted.

     

  • 5. Do you require a Personal Care Attendant (PCA) to travel with you to destinations outside of your home?*

  • Part 3. Ability to Use the Fixed Route (Regular) Bus Service

  • 6. Do you use GTA’s accessible fixed route (regular) bus service(not Access GSO)?*
  • 8. Is there something that may help you to ride the fixed route (regular) bus service?*
  • 9. Are you able to ask for and follow written or verbal instructions about how to use the fixed route (regular) bus?*
  • 10. Are you able to get to and from the bus stop by yourself?*
  • Check reasons that apply*
  • 11. How far can you walk by yourself or with the assistance of a mobility aid?*
  • 12. Are you able to get on and off of the fixed route (regular) bus?*
  • 13. If you are able to get on and off of the bus, can you get to a seat or wheelchair position by yourself?*
  • Check the reasons that apply for getting on and off the bus.*
  • 14. If you are able to get on and off of the bus, do you know where to get off the        bus, and find your way to your destination by yourself?*
  • Check the reasons that apply for getting off the bus and finding your destination.*
  • 15. If you use a wheelchair or scooter, is your home equipped with a wheelchair ramp?*
  • Note: If you are a wheelchair user and your home is not equipped with a wheelchair ramp, and if you are determined ADA eligible, Access GSO will provide pick-ups and drop-offs at your curb, until the GTA Safety Manager reviews whether Access GSO is able to safely serve your residence on a door-to-door basis. If your home is equipped with a ramp, it must be ADA compliant. A site assessment of your residence will be conducted.

     

  • Part 4. Primary Travel Destinations

    Please list the three places you go most often and how you get there now.

  • First Destination
    1. Where do you go?   *   
    Address:   *      *         
    How often do you go there?      times per week or   times per month
    How do you get there now?   *   

  • Second Destination
    1. Where do you go?   *   
    Address:   *      *         
    How often do you go there?      times per week or    times per month
    How do you get there now?   *   

  • Third Destination
    1. Where do you go?   *   
    Address:   *      *         
    How often do you go there?      times per week or   times per month
    How do you get there now?   *   

  • Part 5. Signature

    A. Applicant's Signature

  • Signature of Applicant:   *   Date   Pick a Date*   
    (Applicants must be 18 years of age to sign independently. Otherwise, the signature of a guardian is required.)

  • B. Applicant's Representative

  • If someone else other than the applicant has completed this application, the following information must be provided:
    Name:         
    Daytime Telephone Number:         
    Relationship to Applicant:      Date:   Pick a Date   

  • Note: When you submit this form, you will be redirected to the ACCESS GSO Medical Form, where you will identify your selected professional and agree to the terms of the ACCESS GSO program.

     

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  • Date Received
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