Paratransit Access Line

Part 2

 

Schedules Effective
June 22, 2008
Through Augsut 30, 2008

 

APPLICATION FOR PARATRANSIT SERVICE
Professional Verification

 

Part II
This part must be completed by a licensed or certified health care or rehabilitation professional, who is currently treating you for your disability, or a licensed or certified health care or rehabilitation professional who you visit for a paratransit evaluation, and whose title is listed on page 1, part 2.

Your eligibility will be carefully determined through a certification process in compliance with the regulations of the Americans With Disabilities Act of 1990.  An accurate determination depends on the answers and information provided by you for evaluation.  Inaccurate or false information may lead to denial or suspension of service.

You will be advised of your eligibility status in writing no later than 21 days after our receipt, of both parts of your fully completed application.

If you are denied eligibility, the reason for the denial and procedures to appeal the denial of eligibility will be detailed in that letter.

If you have any questions about the application or the review process, please contact

Paratransit Access Line, at (716) 855-7268 or 855-7377 TDD.

This part of the application form should be completed by one of the following professionals who is currently treating the applicant for their disability, or one of the following professionals who will complete the application for the sole purpose of evaluating how your disability affects your functional mobility:

Pick one item of six to identify your profession:

Physical Therapist certified by the American Physical Therapy Association;

Occupational Therapist certified by the American Occupation Therapy Association;

Certified Rehabilitation Counselor, Case Manager, or Social Worker;

Physiatrist;    

Orientation and Mobility Specialist certified by the New York State Commission For the Blind, or the United States Association for the Education and Rehabilitation of the Blind and Visually Impaired

Qualified Mental Retardation Professional (QMRP);

Applicant Name: ________________________________________

Address: _______________________________________________

City: ____________________State:________Zip Code:_________

1. In what capacity do you know the applicant and for how long?

2. Is the applicant your regular client? Yes or No.

3. Please list the medical diagnoses of all disabilities which functionally prevent the Applicant from:  1) getting to or from a Metro bus stop or rail station; 2) boarding or disembarking an accessible Metro bus or rail car; 3) riding or navigating an accessible Metro Bus/Rail;

4. Is the condition temporary? Yes or No.

If yes, then specify the time frame (example: 6 months) within which you anticipate the applicant to recover. 

5. Is this condition likely to worsen? Yes or No.

6. Does applicant have additional contributing visual and/or mental conditions that prevent travel? Yes or No.

7. Under which category specified below is the applicant applying for eligibility to utilize NFT Metro Paratransit Service(s).  Check all that apply

SECTION 1-Non-Ambulatory Disability

SECTION 2-Mobility Aid

SECTION 3-Arthritis

SECTION 4-Amputation

SECTION 5-Cerebrovascular Accident

SECTION 6-Pulmonary Ills

SECTION 7-Cardiac Ills

SECTION 8-Dialysis

SECTION 9-Disability of Incoordination

SECTION 10-Cerebral Palsy

SECTION 11-Epilepsy

Which statement best describes the applicant’s need for Paratransit Services?  (Check all that apply)

Has a severe physical, mental, or visual disability which makes it impossible to use the NFT Metro accessible Bus/Rail system under any circumstances.

Has a mobility problem which prevents the applicant from boarding an accessible vehicle without the assistance of a personal care attendant

Has a mental or visual impairment which prevents him/her from remembering & understanding all the applicant must do to find their way to and from a NFT Metro Bus/Rail stop and ride the system.  Circle one of the following: The Applicant will never have the ability to learn how to use the NFT Metro System even with mobility training OR With mobility training the applicant is capable of learning how to use the NFT Metro System.                         

The applicant can use the NFT Metro Bus/Rail system sometimes, but for certain trips the individual has not been trained or there are other barriers present.

8. In your opinion, under which of the two circumstances described in the ADA, Section 37.123(e) does the applicant qualify for paratransit service?  (please check one)

Any individual with a disability who is unable, as the result of a physical or mental impairment (including a vision impairment), and without the assistance of another individual (except the operator of a wheelchair lift or other boarding assistance device), to board, ride, or disembark from any vehicle on the system which is readily accessible to and usable by individuals with disabilities.     

Any individual with a disability who has a specific impairment-related condition which prevents such individual from traveling to a boarding location or from a disembarking location on such system.

9.  Does the applicant require use of the following?   (check each, where it applies)

Manual Wheelchair: Yes, no or sometimes

Motorized Wheelchair: Yes, no or sometimes

Cane, crutches, or walker: Yes, no or sometimes

Service animal: Yes, no or sometimes

Personal Care Attendant: Yes, no or sometimes

Sighted Guide/Escort: Yes, no or sometimes

Oxygen: Yes, no or sometimes

10. Is the applicant able to do any of the following with the use of a mobility aid and without the assistance of another person? 

Travel 200 feet: Yes, no or sometimes

Travel ¼ mile: Yes, no or sometimes

Travel ¾ mile: Yes, no or sometimes

11.  Can the applicant climb three 12-inch steps without assistance: Yes, no or sometimes

12. Can the applicant wait outside without support for 10 minutes : Yes, no or sometimes

If No or Sometimes, describe in detail any factors which would have an adverse impact on the applicant’s ability to wait outside.(example: extreme cold):

13. Is the applicant able to:

Give addresses and telephone numbers upon request? Yes or No

Recognize a destination or landmark? Yes or No

Sign his/her name? Yes or No

Deal with unexpected situations? Yes or No

Ask for, understand, and follow directions? Yes or No

Count money and pay fare? Yes or No

14. Does the applicant exhibit disruptive behavior under certain circumstances? Yes or No

If yes, would this behavior endanger him/her or other passnegers? Yes or No

If yes, please describe what type of conditions would be likely to cause such behavior.

15. Please describe in detail the circumstances, under which you believe the applicant could not independently access NFT Metro bus/rail service? 

I have read Part I of this application in its entirety.  (Submitted by Applicant) Yes or No

I agree with the information contained in Part 1 as provided by the applicant.  Yes or No

If no, please explain and provide specifics for each question you disagree with in Part 1.  You may attach an additional sheet if needed.

I hereby affirm that the statements made herein are true and correct.

Name (Professionals Name Printed): _______________________________________________________

Office Address: ___________________________________________________________

City: ______________________________State: ______________Zip Code: ________­­­___

Office Phone:  (_____)________________

New York State License/Certification Number (MUST PROVIDE) __________________________________

Professionals Signature: ___________________________________________
Date: _________                                  

Specialty or Title & Agency: _________________________________________________

Please return this completed form along with Part 1 (previously completed by applicant) to:                        

NFTA Special Services/Paratransit
181 Ellicott Street
Buffalo, New York 14203

NEXT