Application for Certification of ADA Paratransit Eligibility

Dear Customer:

Thank you for inquiring about applying for Salisbury Transit System ADA
Paratransit eligibility. If you have a disability or health condition that prevents you from sometimes or always using Salisbury Transit fixed route bus service, you may be eligible for ADA Paratransit. Enclosed is a copy of an Application for
Certification of ADA Paratransit Eligibility, as well as information outlining the
certification process.

Please read these following carefully before completing the application.

The Americans with Disabilities Act (ADA) of 1990 requires public transit
agencies to provide Paratransit service to people with disabilities who cannot
access the regular fixed route bus service due to their disability or functional
limitation. All of Salisbury Transit buses are equipped with ramps and are
accessible to individuals with disabilities.

ADA Paratransit is a service provided to individuals who are unable to use fixed route bus service because of a disability or functional limitation. An inability to
use fixed-route bus service may include being unable to travel to or from bus
stops, board or exit buses or understand how to ride and use the bus system.

A disability does not guarantee eligibility for ADA Paratransit. Your disability must impact you ability to board, ride and exit a fixed route bus.

There are three types of eligibility:

Conditional Temporary: You are able to use the fixed route bus sometimes and need Paratransit sometimes. The functional limitation is expected to improve.
Conditional Permanent: you are able to use the fixed route bus sometimes and need Paratransit sometimes. The functional limitation will not improve and may become worse.
Unconditional: You cannot use the fixed route bus due to functional limitation

To enable us to accurately determine your eligibility for this service, please
complete the enclosed application as completely and accurately as possible.
The questions are meant to determine the circumstances under which you can use fixed route or Paratransit services.

If you need assistance completing the form, or have any questions, please contact the Salisbury Transit office at 704-638-5252. Upon request, this letter and application is available in large print, and other alternative formats.
After you have completed “Part A” of this application, please have a licensed
health care or rehabilitation professional complete “Part B” of this application and sign the last page. If any sections are left blank, the application will be
returned to you. The information you provide in this application is confidential.

Please do not attach medical documentation or information to this application. You may bring the medical information with you when you have your interview.

Within a few days of receiving your completed application; you will be contacted by telephone to schedule an in-person interview to determine your abilities to use Salisbury Transit fixed-route service. If you need transportation to the interview, we will provide transportation at no cost.

Completed application will be processed within 21 days of receipt. You will then
be notified in writing of your eligibility status. If additional time is required to
complete the evaluation and determination, you will be given temporary eligibility.

If we determine that you are able to use Salisbury Transit fixed route bus service, and are therefore ineligible for ADA Paratransit, we will notify you of the reason(s) for this determination. You may appeal this decision in writing. Appeals will be accepted within 60 days from the date on the eligibility determination letter.

However, ADA Paratransit service will not be provided during the appeal process, unless the appeal process cannot be concluded within 30 days. Eligibility for ADA Paratransit is granted for a period up to three (3) years, regardless of the permanence or temporary nature of the functional limitations.

This application should only be completed if you have a disability or health condition that prevents you from sometimes or always using Salisbury Transit fixed route bus service. Persons completing this application will be considered for ADA Paratransit.

Information about disability or health condition will be kept strictly confidential.

PART A (This section must be completed by all applicants)

Name*

First NameMiddle InitialLast Name

E-mail

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Same as Mailing Address?*

YesNo

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number (daytime)*

Area CodePhone Number

Phone Number (evening)

Area CodePhone Number

Name of Person Assisting:

First NameLast Name

Has someone assisted you with completing this application?*

YesNo

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship to applicant

Phone Number

Area CodePhone Number

Agency

In case of emergency:

Please provide pertinent information for two people ADA
Paratransit can contact. This can be a friend, relative or support professional familiar with your disability.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship to Applicant*

Work Phone*

Area CodePhone Number

Home Phone*

Area CodePhone Number

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship to Applicant*

Work Phone*

Area CodePhone Number

Home Phone*

Area CodePhone Number

1. What is the disability or health condition that prevents you from using SalisburyTransit fixed route buses? Please describe all disabilities or health conditions that affect your travel.*

2. How does this disability or health condition prevents you from using SalisburyTransit fixed route service? Please explain completely. Use additional sheets if needed.*

3. Do you use any of the following mobility aids? (check all that apply)*

4. Do you ever need to bring someone else with you to help you when you travel? (Example: “a personal assistant” or “personal attendant”)*

NoYes, AlwaysYes, Sometimes

Assistant Name

First NameLast Name

Assistant Phone

Area CodePhone Number

Assistant Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

5. Without the help of someone else can you ...

Request and understand written or spoken instructions?*

AlwaysSometimesNeverNot Sure

Cross streets and intersections?*

AlwaysSometimesNeverNot Sure

Stand for 10 minutes if there is no place to sit?*

AlwaysSometimesNeverNot Sure

Step on and off a sidewalk from the curb?*

AlwaysSometimesNeverNot Sure

Find your own way to the bus stop if someone shows you the way once?*

AlwaysSometimesNeverNot Sure

Walk up and down three steps if there is a handrail?*

AlwaysSometimesNeverNot Sure

Stand on a moving bus holding onto a handrail?*

AlwaysSometimesNeverNot Sure

Transfer from one fixed route bus to another?*

AlwaysSometimesNeverNot Sure

Ride fixed route buses if there were a seat or shelter at bus stops?*

AlwaysSometimesNeverNot Sure

6. Under the best conditions, what is the farthest you can walk (or travel using your mobility aid) without the help of another person?*

7. If Salisbury Transit offered free instructions on learning how to ride the fixedroute buses, would you be interested in this type of training?*

YesNo

Please explain:

8. Do you use a wheelchair or scooter?*

YesNo

How wide is it?

How heavy is it when occupied?

This information is not used to determine ADA Paratransit eligibility. It is the
applicant’s responsibility to know the dimensions of their mobility device and
whether it exceeds the definition of a common wheelchair.

The Americans with Disabilities Act of 1990 defines a common wheelchair as
no more than 30 inches wide, 48 inches long and 600 pounds when occupied.
If your mobility device exceeds these dimensions, the ADA does not guarantee
Paratransit service because of legitimate safety requirements.

9. List your 4 most frequent destinations and how you currently get there:*

10. List places you would like to go but cannot currently access:*

Is there anything else you want to tell us about your disability or health condition that might help us to better understand your travel abilities and limitations?

This application has two parts. PART A is completed by the applicant. PART B must be completed by a licensed health care or rehabilitation professional familiar with your disability or health condition and your functional abilities. That individual will be asked to confirm the information you provided in PART A, and that you are UNABLE TO ACCESS Salisbury Transit fixed route bus services due to:

Conditions which prevent you from getting to or from a Salisbury Transit fixed route bus stop, or transferring between vehicles and/or
Conditions which prevent you from being able to get on, ride, or get off a bus with a ramp

Licensed Health Care or Rehabilitation Professional's Name*

First NameLast Name

Licensed Health Care or Rehabilitation Professional's E-mail*

Authorization for Release of Information

I authorize the professional who has completed Part B of this application to release to Salisbury Transit information about my disability or health condition and its effect on my ability to travel on the Salisbury Transit bus service. I understand that I may revoke this authorization at any time.

I, the applicant, understand that the purpose of this application is to determine my eligibility to use ADA Paratransit. I agree to release the information requested to Salisbury Transit System, and any eligibility review panel, and understand that the information contained herein will be treated confidentially, unless otherwise required by law. I understand further that Salisbury Transit reserves the right to request additional information at its discretion. I agree to notify Salisbury Transit of any changes in the status of my disability that affects my ability to use ADA Paratransit service. I also understand that this may affect my eligibility as a rider.

I understand that the purpose of this form is to determine if I am eligible to use ADA Paratransit Services. I certify that the information provided in this application is true and correct. I understand that falsification of information could result in a review of my eligibility and possible loss of ADA Paratransit Services. I agree to notify Salisbury Transit if I no longer need to use ADA Paratransit Services.

Application for Certification of ADA Paratransit Eligibility - PART A