ACCESS GSO Eligibility Questionnaire (Part A)

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
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
HomeWorkCell
Home Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Last Four Digits of Social Security #*
Date of Birth*

MonthDayYear
YesNo
What is your Medicaid ID Number*
Part 2. Disability and Mobility Information
1. Please provide a description of your disability that prevents you from using the GTA accessible fixed route (regular) bus service:*
PermanentTemporaryI don't know
If temporary, how long do you expect it to last? Type a number* months.
YesNo
How?*
NoneWalkerWhite CaneManual WheelchairCaneService AnimalElectric WheelchairCrutchesPortable Oxygen3 or 4-Wheel ScooterLeg BracesProsthesisOther (please specify)

IMPORTANT NOTE

An assessment of your mobility aid will be conducted.

YesSometimesNo
Part 3. Ability to Use the Fixed Route (Regular) Bus Service
YesSometimesNoI used the bus in the past, but stopped.
Why did you stop using the bus?*
7. Please describe why your disability prevents you from using the GTA accessible fixed route (regular) bus service*
Route and schedule informationBeing able to use the bus lifeAttending a Travel Training course to learn how to ride the busOther
Which route and/or schedule information would be helpful?*
Yes, by myselfYes, with a Personal Care AttendantI probably could with specific instructionNo, I get too confused and might get lostNo, other people cannot understand me
Why can people not understand you?*
YesNo
I cannot travel outside of my house or apartmentI can only get to the curb in front of my house or apartmentI can if someone is with me to assist meI cannot get to places where there are no curb cutsI cannot cross busy streets or intersectionsI cannot travel outside when it is too hotI cannot find my way at night due to a vision problem
I can travel less than 1 blockI can travel 4 blocksI can travel 1 blockI can travel 5 blocksI can travel 2 blocksI can travel 6 blocksI can travel 3 blocks
YesYes, but only if the bus has a wheelchair liftYes, but only if a personal care attendant (PCA) is with meNoSometimes
When?*
YesNo
I need someone to help meI have a balance problemI have trouble finding a seat
Reason I have trouble finding a seat*
YesNo
I can if the driver calls out the stopsI probably could with trainingI get confused and can't remember where I am going
YesNoI do not require a 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?   Name of Destination*
Address:   Street Address*      City*
How often do you go there?   Weekly Number   times per week or   Monthly Numbertimes per month
How do you get there now?   Current Transportation*
Second Destination
1. Where do you go?   Name of Destination*
Address:   Street Address*      City*
How often do you go there?   Weekly Number   times per week or   Monthly Number times per month
How do you get there now?   Current Transportation*
Third Destination
1. Where do you go?   Name of Destination*
Address:   Street Address*      City*
How often do you go there?   Weekly Number   times per week or   Monthly Numbertimes per month
How do you get there now?   Current Transportation*
Part 5. Signature

A. Applicant's Signature
Signature of Applicant: Signature* Date 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:   First Name   Last Name
Daytime Telephone Number:   Area Code   Phone Number
Relationship to Applicant:   Relationship   Date:   Date

Office Use Only
New CertificationRecertification
Date Received

MonthDayYear
Completed Medical Form

Cancelof
Should be Empty:

ACCESS GSO Eligibility Questionnaire

Part 1. General Information

Part 2. Disability and Mobility Information

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

Part 4. Primary Travel Destinations

Part 5. Signature

A. Applicant's Signature

B. Applicant's Representative

Office Use Only