Application for Certification of ADA Paratransit Eligibility

Hello,

You are being asked by the applicant named in PART A of this application to provide information regarding his/her ability to use Salisbury Transit fixed route transit services. SalisburyTransit system may provide ADA Paratransit services to individuals who have a disability or health condition that prevents him/her from sometimes or always using Salisbury Transit fixed route bus service. 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. The information you provide will allow us to evaluate the request and determine this individual’s specific needs. Thank you for your
cooperation in this matter.

PLEASE NOTE: Salisbury Transit fixed route bus service is available in Salisbury, Spencer, and East Spencer and are currently accessible to persons with disabilities who need ramps to board and exit the bus, vehicles which kneel to the curb, and/or announcement of bus stops. The individual applying for ADA Paratransit MUST BE UNABLE TO ACCESS THESE SERVICES due to:

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

Individuals for whom performing these tasks is inconvenient or uncomfortable are NOT ELIGIBLE for services, and you are asked to verify this.

PLEASE FOLLOW THESE STEPS TO VERIFY THIS APPLICATION:

Read PART A of the application in its entirety (this was received as a pdf attachment to your notification email)
Fill out PART B of the application completely, using the criteria
provided
Complete PART B of the application within 7 days of receipt.
You may be contacted for additional information if questions remain about the applicant’s abilities.
If you have any questions, contact Salisbury Transit at (704) 638-5252.

I have read PART A of this application in its entirety:*

YesNo

If no, please explain:

I agree with the information provided in PART A:*

YesNo

If no, please explain:

1. Name of the applicant from PART A:*

First NameMiddle InitialLast Name

Applicant's E-mail

2. Capacity in which you know the applicant:*

3. When was the applicant last treated or seen by you?*

4. On average, how frequently is the applicant seen by you?*

5. Has the applicant been diagnosed with physical, cognitive, mental, or otherdisability that would prevent him or her from using Salisbury Transit fixed routebus service? *

YesNo

Diagnosis and date of onset:

6. The applicant's disability is:*

PermanentTemporary

Applicant's disability is temporary until:

7. Do the applicant’s functional abilities to travel change due to medical treatments, environmental conditions (heat, humidity, cold, ice and snow) or other related factors?*

YesNo

Please explain:

8. Additional comments (prognosis, functional abilities, etc.):

9. Please choose the statement below which best represents your opinion regarding this individual’s use of public transportation:*

This individual should be able to access the fixed-route bus service successfully.This individual can use the fixed-route bus service under certain situations as stated above.This individual cannot use the fixed-route bus service due to multiplefunctional limitations.

Your Name*

First NameLast Name

Your Title*

License or Certificate #*

Your E-mail

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Company/Agency Name

Your Phone

Area CodePhone Number

Fax Number

Area CodePhone Number

Completion of this application by any other profession will not be accepted. Professional affiliation (check the appropriate designation):

Licensed physicianLicensed physical therapistLicensed occupational therapistCertified rehabilitation counselorCertified psychologist/psychiatristCertified orientation/mobility specialist

I verify that PART B of this application has been completed accurately to the best of my knowledge. I verify that I am a licensed health care or rehabilitation professional familiar with the applicant who completed PART A, with their disability or health condition and their functional abilities.

Application for Certification of ADA Paratransit Eligibility - PART B