Application Mobility Aid UCAT ADA 2008
User Manual: Mobility Aid
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1 Danny Circle Kingston, NY 12401 (845) 340-3333 www.co.ulster.ny.us/ucat ADA PARATRANSIT CERTIFICATION APPLICATION Date / / 1. Name Address Apt # City/Town State Zip Is this a (check one) Private home Group home Residential care facility Nursing home Apartment complex Other, please specify: Phone No.: (Home) Date of Birth (Work) / / Sex: M F 2. What is your disability? (Please describe, in detail, how your disability prevents you from using the regular UCAT bus service): 1 3. Is your disability temporary? , it is a permanent condition. No Yes , I expect it to last for another months. 4. Have you had this disability for more than a year? Yes No 5. How far can you travel without assistance or when using a mobility aid? 6. Does your disability or condition change from day to day in ways that affect your ability to use the regular bus service? , my condition does not change much from day to day. No Yes , my condition is good on some days and bad on other days. Please explain: If you have a disability that changes from day to day (you answered yes to question #6 above): A. On a day when my condition is good: (choose only one answer) I can’t leave my house I can get to the curb in front of my house I can go one block I can go two blocks I can go four blocks (about ¼ mile) I can go six blocks or more (about ½ mile) B. On a day when my condition is bad: (choose only one answer) I can’t leave my house I can get to the curb in front of my house I can go one block I can go two blocks I can go four blocks (about ¼ mile) I can go six blocks or more (about ½ mile) 7. Does the weather ever keep you from using the regular UCAT bus service? _____Yes _____No If yes, what kind of weather and how does this weather keep you from using the regular UCAT buses? _____________________________________________________________________ _____________________________________________________________________ 2 _____________________________________________________________________ 8. When the weather affects your ability to use the regular UCAT buses, how far can you travel on your own or with a mobility aid? A. When the weather is good, and my condition is good (Choose only one answer): _____ I can’t leave my house _____ I can get to the curb in front of my house _____ I can go one block _____ I can go two blocks _____ I can go four blocks (about ¼ mile) _____ I can go six blocks or more (about ½ mile) B. When the weather is bad, but my condition is good (choose only one answer): _____ I can’t leave my house _____ I can get to the curb in front of my house _____ I can go one block _____ I can go two blocks _____ I can go four blocks (about ¼ mile) _____ I can go six blocks or more (about ½ mile) 9. Do you need to travel with someone who assists you (e.g. personal care attendant)? _____ Always _____ Sometimes _____ No If you need someone to travel with you always or sometimes, do you need this person to help you: _____ Get to the bus stop _____ Get on or off the bus _____ While you ride the bus _____ Get where you are going once you are off the bus _____ Other (please specify): ____________________________ ______________________________________________________________________ 10. Which of the following mobility aids or equipment do you use to help you get where you need to go? (Check all that apply) _____ Cane _____ Crutches _____ Walker _____ Respirator/oxygen tank _____ Personal care attendant 3 _____ Powered wheelchair (Please specify manufacturer and model): ___________________________________________________________ _____ Powered scooter (Please specify manufacturer and model) ___________________________________________________________ _____ Service animal (please specify type): ___________________________________________________________ _____ Prosthesis _____ Braces _____ Manual wheelchair _____ Other, please specify: __________________________________________________________ _____ I do not use a mobility aid, personal care attendant, or service animal. 11. If you use a manual or powered wheelchair or scooter, is it more than 30 inches wide, more than 48 inches long, or does it weigh more than 600 lbs.? _____ Yes ____ No 12. Do you need assistance to get to the bus from your door? _____ Yes ____ No 13. If you use a wheelchair or scooter, can you transfer to a seat? _____Yes _____No 14. Which of the following limits your ability to use regular UCAT buses (Please check all that apply): _____ Physical disability _____ Visual impairment/blindness _____ Developmental disability _____ Mental illness _____ Other (please specify): ______________________________________________________________________ Why? Please describe in detail: 4 15. How are your transportation needs being met now? (Please check all that apply) _____ Walking _____ Personal transportation (i.e. car) _____ Public transportation _____ Agency sponsored rides (please specify): ________________________________________________________________ _____ Paratransit (please specify): ________________________________________________________________ _____ Ambulance (please specify): ________________________________________________________________ _____ Friend/relative _____ Other (please specify): ________________________________________________________________ 16. Do you use UCAT buses? _____Yes How many days in one week? ___________ How many days in one month? ___________ _____ No Why? ______________________________________________________ ______________________________________________________ ______________________________________________________ 17. Is there something that would help you to ride the regular UCAT bus? _____ Yes _____ No Please explain: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ If you check yes, please mark all that apply below: 5 _____ Knowing more about regular buses _____ being travel trained to go to work or school (Travel training can include system orientation, specific destination training, handling travel emergencies (use of a public phone, detours, missing stops, etc.), demonstrating awareness of personal safety, and 100% proficiency in street crossing.) _____ if the bus has a lift (accessible bus) _____ if a communication aid (stop assistance aid, hailing card, etc.) was available _____ learning to travel with crowds, noises, traffic _____ I would ride if there were accessible bus routes where I need to go. _____ I would ride if there were no barriers to prevent me from getting to/from the places I need to go. _____ other, please specify: _______________________________________________________ 18. Are you currently able to travel by yourself on public transportation? _____ Always ______ Sometimes _____ Never _____ Not Sure If you checked never or not sure, please explain why: ________________________________________________________________ ________________________________________________________________ 19. Can you transfer from one regular UCAT bus to another? _____ Always _____ Sometimes _____ No _____ Possibly, if trained If you checked no or possible, if trained, please check all that apply: _____ I find it confusing _____ I can transfer if it is someplace I go all the time _____ I do not like to transfer _____ I do not want to use the bus _____ Other ______________________________________________________ 20. Using a mobility aid or on your own, can you make your way to or from the bus stop nearest your home? _____ Yes, always _____ Yes, sometimes _____ No _____ I do not know because I have never tried 6 21. If you cannot make your way to the bus stop nearest your home (No, to above question), please check all that apply below: _____ I do not know where the bus stop is _____ I do not want to ride the buses _____ I cannot go that far _____ Barriers like sidewalks, curbs and steps keep me from getting there _____ I possibly could with training _____ I cannot travel to the bus stop in bad weather _____ I can travel to the bus stop when my condition is good, but not when I am having a bad day _____ other, please specify: ________________________________________________________________ 22. Most of the time, can you: A. Cross the street, if there are curb cuts? _____ Always _____ Sometimes _____ Never _____ Not sure _____ Never _____ Not sure B. Cross a two-lane street? _____ Always _____ Sometimes 23. Can you wait 15 to 20 minutes at a bus stop? _____ Always _____ Sometimes _____ No, I can only wait _____ at a bus stop _____ I do not know because I have never tried If no, why? ____________________________________________________________ ______________________________________________________________________ 24. Can you get on and off a regular bus when it has a passenger lift, by using the steps, getting the bus to kneel or using the lift with a mobility aid? _____ Always _____ Sometimes _____ No _____ I do not need a lift _____ I have never tried If you answered “sometimes” or “no” to the above question, please check all that apply below: _____ my mobility aid will not fit on the lift _____ I cannot steady myself when the lift is moving _____ I do not feel secure on the lift _____ I possibly could with training _____ other, please specify: 7 ______________________________________________________________________ 25. Have you ever had any training to learn how to use the regular buses? 26. _____Yes _____No If yes, please continue. If no, please go to question #26. _____ Yes, I was trained by: ________________________________________________________________ I was trained in: month __________ year ___________ I learned: (please check all that apply) _____ to travel to and from bus stops _____ general bus travel _____ how to read bus destination signs _____ getting on or off the bus _____ how to communicate with bus drivers _____ asking for help or saying no when offered help _____ destination or site training (point A to point B) _____ how to handle problems or travel contingencies _____ specific destination training _____ how to cross streets with 100% accuracy _____ how to use public phones _____ demonstrate awareness of personal safety _____ I started but did not finish the training. Why? ___________________ ________________________________________________________________ ________________________________________________________________ _____ I received training but to learn to ride specific bus routes. Please list the bus routes: ________________________________________________________________ ________________________________________________________________ _____ I learned to travel to a specific place on the following bus routes: Place/Address __________________________________________ __________________________________________ __________________________________________ Route _______________ _______________ _______________ 26. Please list your most frequent trips and how you get there now: A. Origin __________________________________ Round trip: ________________ 8 Destination______________________________________ How Often? ___________ Address _________________________________City__________________________ _____by UCAT bus _____other, please specify: ______________________________________________________________________ B. Origin _________________________________ Round trip: _________________ Destination______________________________________ How Often? ___________ Address __________________________________City_________________________ _____by UCAT bus _____other _____________________________________ C. Origin __________________________________ Round trip: ________________ Destination______________________________________ How Often? ___________ Address __________________________________City_________________________ _____by UCAT bus _____other, please specify: ______________________________________________________________________ 27. Do you have a UCAT half fare card? _____Yes _____No 28. Do you currently use regular buses? _____Yes _____No When was the last time you used a bus: _____ this week _____ last week _____ one month ago _____ longer than a month _____ never 29. List the bus routes serving your neighborhood: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 30. If you use the buses now, which routes do you use? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 9 31. How far is the UCAT bus stop from your home? What is the location of that stop? Can you get to that stop by yourself? Yes No Sometimes If no, why not? ________________________________________________________ 32. How would you describe the terrain where you live? (e.g: steep hill, long gradual hill, flat, etc.) ______________________________________________________________________ ______________________________________________________________________ 33. Are there any sidewalks at your residence? _____ Yes _____ No 34. Are there any curb cuts on your block? _____ Yes _____ No 35. How many steps are there at the entrance of your residence?___________________ 36. Do you have a ramp? _____ Yes _____ No If yes, where is it located? ________________________________________ 37. If a certified travel or mobility trainer were to assess your skills to travel independently and found you to be eligible, would you be interested in learning to travel to or from your workplace (or any other specific destination) if paratransit could still be used for destinations for which you are not travel- or mobility-trained? _____ Yes _____ No 38. Due to my disability I need (check all that apply): _____ a seat in the front of the bus _____ the stops announced _____ the bus to remain stopped until I am seated _____ all tie downs to be working _____ all tie downs to be secure _____ the lift to be functional _____ the kneeling device to be operational _____ other, please be specific:_____________________________________ 39. Is there anything else you want to tell us about your health condition, disability or transportation needs? 10 ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ________________ I understand that the purpose of this form is to determine if I am eligible for ADA paratransit service. UCAT or its contracted agents may need to talk to me or to see me later to get more information. I understand that I must be truthful in answering the questions on this form and at any in-person assessment. Giving false information is against the law and may result in the lost of my paratransit service, and/or criminal penalties. I agree to notify UCAT if I no longer need to use paratransit. I hereby certify that the information given in this application is true to the best of my knowledge. I understand if UCAT or its authorized agents receive new information regarding a change in my functional mobility, my eligibility status may be reviewed and changed. I understand that UCAT or its authorized agents will notify me in writing of any change in my eligibility status and I may appeal such decision within sixty (60) days of notification. ______________________________________________ (Applicant’s Signature) _____/_____/_____ (Date) (If applicant is unable to sign, Power of Attorney may sign for applicant. Please enclose copy of POA. If applicant is under age 18, parent or guardian may sign for applicant) To establish your eligibility, it may be necessary to have you consult with our health professional. You will be contacted if this is needed. Should future correspondence be sent to the applicant, or to someone else? _____ Yes, send it to the applicant _____ No, send it to (name and address) _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ If you are completing this application on behalf of the person requesting certification, please complete and sign below: Name: _______________________________________________________________ Relationship to applicant: ______________________________________________ 11 Address: _____________________________________________________________ City/Town __________________________________ State __________ Zip________ Daytime Telephone (______)_______________________ Signed __________________________________________ Date _____/_____/_____ It may also be necessary to contact your own health care or rehabilitation professional. These may include a physician, physical therapist, occupational therapist, social worker, vocational counselor, or agency representative. Please scroll down and complete and sign the following authorization. You will need to send the completed form below, by mail, to UCAT at 1 Danny Circle, Kingston, NY 12401. 12 I authorize the ADA Transit Office of Ulster County Area Transit (UCAT) to contact the health care or rehabilitation professional listed below to obtain information regarding my disability and its affect on my ability to get around on my own. Name of Health Care Professional___________________________ Street Address_____________________________________________ City/Town _____________________ State __________ Zip________ Telephone Number (____)______________________ Name of Health Care Professional___________________________ Street Address_____________________________________________ City/Town _____________________ State __________ Zip________ Telephone Number (____)______________________ Name of Health Care Professional___________________________ Street Address_____________________________________________ City/Town _____________________ State __________ Zip________ Telephone Number (____)______________________ _______________________________________________ (Applicant's Signature) ___/___/___ (Date) _______________________________________________ (Guardian's Name and Signature, if applicable) ___/___/___ (Date) 13 The next page must be torn off and given to doctortherapistcounselor to complete 14 MEDICAL VERIFICATION FOR ADA PARATRANSIT SERVICES IMPORTANT NOTICE: The information, which you provide, will assist UCAT in determining your patient's functional and cognitive ability to use public transportation. This form assists UCAT in determining when and under what circumstance the consumer can utilize the bus system. All of our vehicles are equipped with a wheelchair lift for individuals who need to use a wheelchair or cannot climb stairs. It is essential that you be as precise as possible in your evaluation. All information on this form will be kept strictly confidential and will not be released. Thank you for your cooperation. 1. NAME OF PHYSICIAN OR HEALTH CARE PROFESSIONAL COMPLETING FORM: ___________________________________________________________________ OFFICE ADDRESS: __________________________________________________ OFFICE PHONE #: ______________________________ CAPACITY IN WHICH YOU KNOW THE APPLICANT: ___________________ 2. PLEASE DESCRIBE THE CONDITION (WHETHER PHYSICAL OR COGNITIVE) WHICH FUNCTIONALLY PREVENTS THE APPLICANT FROM USING REGULAR BUS SERVICE. BE AS SPECIFIC AS POSSIBLE IN YOUR DESCRIPTION: ________________________________________________________________________ 3. PROGNOSIS / EXPECTED DURATION OF DISABILITY: ________________________________________________________________________ 4. DOES THE APPLICANT NEED A WHEELCHAIR FOR AMBULATION OUTSIDE OF THEIR HOME? Yes ____ No ____ 5. FUNCTIONAL ASSESSMENT TASK DESCRIPTION CANNOT PERFORM TASK PERFORMS TASK WITH ASSISTANCE PERFORMS TASK INDEPENDENTLY PERFORMS TASK WITH ASSISTANCE PERFORMS TASK INDEPENDENTLY Climb Stairs Read Information Signs Hear Spoken Directions Able to Use Bus 6. COGNITIVE ASSESSMENT TASK DESCRIPTION CANNOT PERFORM TASK Can applicant give address and telephone number upon request Can applicant recognize a destination or landmark Can applicant deal with unexpected situations or an unexpected change in routine Can applicant ask for, understand and follow directions Can applicant safely and effectively travel through crowded and/or complex facilities Doctor’s Signature: _____________________________________ Date: ________________________ Print Name and Title:_____________________________ Telephone: _______________Patient Name: ___________ 15
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