ADA PARATRANSIT APPLICATION

Dear FRTA Applicant,

Persons with disabilities may be considered eligible to use FRTA ADA service if they meet the following criteria:

If the person's disability prevents him/her from getting to and from a station/stop at the point of origin or destination.

If the person's disability prevents him/her from boarding, utilizing or disembarking from the vehicle at the station/stop, even with the assistance of a lift-equipped bus.

If the person's disability prevents him or her from recognizing the pick-up point or the destination point once the person is on the vehicle.

If the person's disability would not allow the person to negotiate transfers or connections if any should exist, on the desired fixed-route path of travel.

Architectural or environmental barriers not under the control of the FRTA (e.g. distance, terrain, lack of curb cuts, weather) standing alone, do not form a basis for eligibility.  The interaction of such barriers with an individual's specific impairment-related condition may form a basis for eligibility, if the effect is to prevent the individual from traveling to a boarding location or from a disembarking location.

A determination of your eligibility will be made by the FRTA within 21 days of receipt of the completed application.  The FRTA will notify you in writing of the decision about your eligibility for ADA paratransit service.  If it is determined that you are able to use the fixed route system and are not eligible for paratransit service, the FRTA will explain the reason for this determination.  An opportunity to appeal a FRTA decision will be available. The appeal process will be described in detail in the denial letter.

If your application is approved, you will be given information on how to use the appropriate service(s) and will need to stop by our offices so that an ADA photo ID card can be issued.  If you are considered temporarily disabled by the FRTA then you will be granted TEMPORARY eligibility, which may be renewed (if necessary depending on your medical situation).  Your eligibility may be reassessed periodically by our office.

ASSESSING YOUR ELIGIBILITY FOR SERVICES

If you are applying for ADA Paratransit, please complete the ADA Paratransit Application that is attached.

Remember, in order to be eligible for this service, you must reside within 3/4 of a mile of our fixed route corridor and the time of your trip must fall within the hours of the closest FRTA bus route.  If you do not reside within the 3/4 radius, than you must have a means of getting within our service area before transportation is provided.

Please complete your application as thoroughly as possible.  The questions will assist us in determining the specific limitations you have in using our service. 

It will be necessary for a licensed medical professional (not a relative or friend) that sees you on a professional basis to complete the Medical verification portion of your application.  This person may be a registered nurse, social worker, physician, physical therapist, psychologist, occupational therapist, chiropractor, speech pathologist, physician's assistant, nurse practioner, or mental health counselor employed by a medical facility.  Contact our office if assistance is needed in completing your application.  Incomplete applications will be returned and not considered until all information (including the medical verification portion) is received.
Faxed copies will not be accepted.

All applications and certifications will be kept strictly confidential and will not be released. We do reserve the right to verify the information reported on the application by contacting persons noted on the form.

The FRTA may retain the services of a registered occupational therapist or a registered physical therapist if consultation about a disability is thought necessary.

Please return your completed application to:

                                      Franklin Regional Transit Authority

                                      474 Main Street

                                      Greenfield, MA 01301

                                      Telephone: (413) 774-2262 ext. 103 (TTY also)

Persons wishing to communicate with the FRTA using a TTY should call our main number at (413) 774-2262.  Please allow time to set up our machine.

All information relative to the FRTA ADA paratransit program is available (by request) in alternative forms such as Braille, cassette tape and large print formats. 

ADA PARATRANSIT APPLICATION

This application will be used solely to determine ADA eligibility for Franklin Regional Transit Authority.  Transportation is primarily curb-to-curb, however, if needed arrangements may be made for door-to-door service. Please complete this application to the best of your ability.  The FRTA's ADA paratransit services are for disabled individuals who are available within 3/4 mile of our fixed route corridor and cannot navigate or access our fixed route service due to their disability.  Transportation is provided from your point of origin to your destination point and is available only when our regular fixed route buses operate (please refer to the attached fixed route schedule for our service area and route times).  The fact that accessing the fixed route is difficult, inconvenient or does not travel near or to your home or point of destination is not sufficient grounds for eligibility.

ADA service is available on a "next day basis", but costs twice the fare amount of our regular fixed route service.

PLEASE PRINT OR TYPE

LAST NAME:  _____________________   FIRST NAME: _______________  MI: _____

STREET ADDRESS: __________________________________________ APT.  _____

MAILING ADDRESS (IF DIFFERENT):  _______________________________________

CITY OR TOWN: ______________________________________ ZIP: ____________

TELEPHONE: ____________________________  DATE OF BIRTH: _____________

Please give us the name and telephone number of someone we can call in the event of
an emergency.

Name: __________________________________  Telephone: ____________________

Relationship to you: ______________________________

If this application is being filled out by someone other than the person requesting certification,
please complete the following:

Name: __________________________________  Telephone: ____________________

Relationship to applicant:  ____________________________________

Signature: ________________________________________________

1.  Please choose what type or types of disabilities prevent you from using our fixed
     bus route (you may choose more than one). 

Physical disability _____   Visual Impairment/blindness______

Mental impairment_____       Developmental disability_____           Other ______

Please describe your disability/disabilities in more detail:
___________________________________________________________________

2. Explain how your disability prevents you from utilizing our fixed bus service:
___________________________________________________________________

Is this condition permanent  _____   or temporary ______ ?

If temporary, how long do you expect your condition to last? _____________________

3. Please indicate the use of any of the following mobility aids or equipment*:

cane ____     walker ____     manual wheelchair ____     powered scooter ____

leg braces ____   crutches ____    powered wheelchair ____    walker ____

service animal ____     segway ____     prosthetic device ____   other  _____________

Do you need to use a wheelchair outside of your residence?   Yes ___   No ___

*Please note that we may not be able to accommodate you if your wheelchair/scooter is
longer than 48" or wider than 30" or if your total weight with your wheelchair/scooter
exceeds 600 pounds.

4.  Do you need to travel with someone who will assist you with your trip? 

Always ____       Sometimes ____       Never _____ 

If you travel with someone who assists you, does this person assist you:

Getting to or from a bus stop  ______

Getting on or off a bus _____

At your home or destination ______

5.  Have you ever used the fixed route bus system?

Yes, I use the bus _____ times per week.

Yes, I used to but stopped because ________________________________________

No, I have never tried because ___________________________________________

6.  Can you ask for and follow written or verbal instructions to use the bus system?

Yes ____   No ____  Sometimes ____  I do not know because I have never tried ____

If no or sometimes, please check all that apply:

I get too confused and might get lost _____

Other people cannot understand me  _____

I probably could, but with specific instruction  _____

Other ___________________________________

7.  Are you able to get to and from our service area on your own?

 Yes ____  No ____ Sometimes ____  I don't know,  I have never tried ____

If no or sometimes, please check all that apply:

I cannot get places if there are no curb-cuts  ____

I cannot cross busy streets and intersections  ____

I cannot travel outside when the weather it is too hot  ____

I cannot because the sidewalk or street is too steep  ____

I cannot travel in snow or icy conditions  ____

I get confused and cannot find my way  ____

8.  If you are able to get to and from the bus, can you board the bus by yourself?
(Keep in mind that the only assistance offered by the driver is operating the
wheelchair lift and kneeling devices). 

Yes ___  No ___  Sometimes  ___  I don't know, I have never tried  ____

If no or sometimes, please check all that apply:

I cannot climb stairs ____

I need assistance other than what the driver provides ____

I do not want to use the lift ____

I might be able to with training ____

Other _____________________________________________________

9.  Is there something that might help you to ride the bus (check all that apply):

Yes, if someone taught me to understand the route, schedule and fare information ___

Yes, if someone were to show me how to ride the bus  ___

Yes, learning how to get on the bus using the lift ___

Yes, if the bus were to come closer to where I live and need to go ___

No, none of these would help ___

10.  Once on the bus, can you walk to a seat or maneuver your wheelchair to a tie
down position? 

Yes ___  No ____  Sometimes ____  I don't know, I have never tried ____

If no or sometimes, please check all that apply:

I have a balance problem ___

I probably could if someone showed me ___

I need assistance other than what the driver can provide  ___

11.  If you use a mobility aid on your own, how far can you travel?

I cannot travel outside of my residence by myself ____

I can get to the curb in front of my residence by myself ____

I can travel up to 1/4 mile (3 blocks) alone ___

I can travel up to 1/2 mile (6 blocks) alone  _____

I can travel up to 3/4 mile (9 blocks) alone ____

I can travel more than 3/4 mile alone ____

12.  Can you deal with unexpected situations and unexpected changes in routine? 

Yes ___  No ___  Sometimes ____ 

If no or sometimes, please explain: ______________________________________

13.  Can you recognize landmarks in order to travel on the bus route independently?

Yes ___  No ___  Sometimes ____

If no or sometimes, please explain: ______________________________________

14.  Do you have any other conditions which would limit your ability to use our
       bus system? 

Yes ___  No ___

If Yes, please explain: _________________________________________________

15.  Have you ever had training on how to use the regular fixed bus route?

Yes ___  No ____  In the process of ____

Would you like to be trained for this?   Yes  ____  No  ____

16.  Are you able to identify when a vehicle has arrived to pick you up?

Yes ____  No ____  Unsure  ____

17.  I hereby understand that in order to be eligible to use ADA Paratransit service, I must have a disability which makes me unable to use the FRTA fixed route service.  I agree that if any of the information given to the FRTA is materially false or misleading, the FRTA shall have the right to reconsider my eligibility for ADA paratransit services.  I certify that the information given above is correct.  I understand that the FRTA may contact the health care professional who has completed the medical verification attached to this application in order to confirm information included in this application.

SIGNED: ____________________________________  DATE: __________________

In order to allow the FRTA to evaluate your application it will be necessary to have your Physician or other Professional confirm the information you have provided and return it with your application. Faxed copies will not be accepted.

 

MEDICAL VERIFICATION FOR ADA PARATRANSIT SERVICES

IMPORTANT NOTICE:  The information, which you provide, will assist the FRTA
in determining your patient's functional and cognitive ability to use public transportation.
This form assists the FRTA 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 :  _______________________

3.  PROGNOSIS / EXPECTED DURATION OF DISABILITY:  ________________________________________________________________________

TASK DESCRIPTION	CANNOT PERFORM TASK	PERFORMS TASK WITH ASSISTANCE	PERFORMS TASK INDEPENDENTLY
Climb Stairs
Read Information Signs
Hear Spoken Directions
Able to Use Bus

TASK DESCRIPTION	CANNOT PERFORM TASK	PERFORMS TASK WITH ASSISTANCE	PERFORMS TASK INDEPENDENTLY
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

Below for FRTA use ONLY:     Date Received ______________

FRTA 474 Main St., Greenfield, MA 01301

_____________________________________