WIXLIB

ADA Paratransit ApplicationThe GoRaleigh ACCESS program, a paratransit system operating inaccordance with the Americans with Disabilities Act (ADA) of 1990, isdesigned to serve individuals whose disabling conditions or functionallimitations prevent them from using regular fixed route GoRaleigh.The ADA program allows paratransit trips to be made at the cost of 2.50 per trip for eligible users.WHO IS ELIGIBLE?Under the ADA regulations, individuals who qualify for paratransitservices qualify for at least one of following three categories:1. The individual is unable, as a result of mental or physicalimpairment as defined in the ADA, to get on, ride, or get off anaccessible vehicle of the GoRaleigh fixed route bus system;2. The individual needs the assistance of a wheelchair lift or otherboarding device and is able, with such assistance, to get on, ride,and get off an accessible vehicle, BUT such a vehicle is notavailable on the route when the person wants to travel;3. The individual has a specific impairment-related condition(including limitations of vision, hearing or disorientation), whichprevents travel to or from a transit station or stop of theGoRaleigh fixed route bus system.If at least one of the above items applies to you, identify whichitem number(s) above .GoRaleigh ACCESS ProgramPage 13/18/2016

ELIGIBILITY:PROGRAM:WHATYOUSHOULDKNOWABOUTTHIS Individuals who can access regular fixed route bus services arenot eligible for paratransit service. Paratransit service operates only within the Raleigh ADA servicearea. If you qualify for ADA service, but live outside this area, youare responsible for any transportation needed to arrive within 3/4mile of the service route. If the applicant is determined to be eligible for this program, oneof two designations may be made: Unconditional or Conditional.Unconditional eligibility indicates that the applicant can useparatransit service for all trips within the service area.Conditional eligibility indicates that some trips are eligible andsome not, based on functional ability to use the GoRaleigh bussystem, given the specific environment and demands of eachtrip.HOW TO APPLY:1. Review the GoRaleigh ACCESS brochure and this ADAapplication. Additional copies are available from the City ofRaleigh Transportation Department (996-3459), GoRaleigh, andsome Wake County libraries, doctor’s offices, and social serviceagencies.2. If you believe you qualify for ADA paratransit services, completepart A of this application.3. Provide the application - both parts A &B - to an authorizingprofessional. Both parts of the application must be completed inorder for your application to be considered.4. Mail the completed application (both parts A & B) to:City of Raleigh Transportation DepartmentGoRaleigh ACCESS, Attn. ADA paratransit EligibilityP.O. Box 590, Raleigh, NC 27602GoRaleigh ACCESS ProgramPage 23/18/2016

WHAT HAPPENS AFTER I TURN IN MY APPLICATION?1. After the City of Raleigh has received your application, you willbe contacted by Medical Transportation Management, Inc.(MTM) staff to schedule a functional assessment.2. A representative of MTM will meet with you to determine youreligibility based on the following factors:a. Information provided on your application.b. Information provided by your authorizing professional.c. Results of a brief assessment of your actual functionalabilities.d. A review of available transportation options in the areas inwhich you desire to travel.If you have questions or have not been contacted within 21daysof submitting your application, call GoRaleigh ACCESS at (919)996-3459. If you use a TDD, call 1-800-735-2962 and ask to beconnected to (919) 996-3459. If, at that time, a determination ofyour eligibility has not been made, you will be temporarily eligiblefor paratransit service until such time as your application can bereviewed.3. If you are denied paratransit eligibility, you will receive a letterregarding this decision and a copy of the GoRaleigh ACCESSAppeals Process. You have the right to appeal. For moreinformation, contact GoRaleigh ACCESS at (919) 996-3459. Ifyou use a TDD, call 1 (800) 735-2962 and ask to be connectedto (919) 996-3459.This application is available in alternative formats. If you wouldlike additional assistance, please call (919) 996-3459 (TDD userscall 1-800-735-2962, and ask to be connected to (919) 996-3459).The information in this application will be used only todetermine your eligibility for ADA paratransit services and willbe kept confidential.GoRaleigh ACCESS ProgramPage 33/18/2016

GoRaleigh ACCESSADA PARATRANSIT APPLICATION - PART APlease complete the following information:Name:Birthdate: / /Address:City: State:Zip:Home telephone number:Work/ Other daytime telephone number:If hearing impaired, TDD number:Do you currently use any city transportation, including GoRaleigh,regular fixed-route bus system?NOYESIf yes, which routes?What is the closest bus stop to your home?Can you get to the bus stop by yourself? YESNOIf no, what limits you from getting there?Name any GoRaleigh routes, which serve your neighborhood:Language Ability (please check all that apply):EnglishSpanishOther (specify):GoRaleigh ACCESS ProgramPage 43/18/2016

Please check ONE of the following seven statements, which bestdefines the nature of the disability or limitation which preventsyou from using GoRaleigh fixed route bus service. Describeyour specific needs in the space provided:(MOB)I have a mobility impairment, which prevents me fromgetting to and/or getting on a fully accessible vehiclewithout assistance. Describe the nature of thiscondition and any environmental obstacles (such asinclines, curbs, and distances) which affect yourability to access public transportation:This condition is:(END)I have an endurance problem, which prevents me frommoving the distance needed to get to the bus stop.Please describe the cause and nature of this condition:This condition is:(VIS)temporary permanenttemporary permanentI have a visual impairment that prevents me from findingmy way to and from a GoRaleigh bus stop withoutassistance.Describe the nature of your condition and your functionallevel of vision:Please list any specific trips for which you have receivedtravel training and the name of the Orientation andMobility specialist who provided the training:GoRaleigh ACCESS ProgramPage 53/18/2016

(COG)I have a cognitive disability which prevents me fromremembering and understanding information needed toget myself safely to and from the bus stop. Pleasedescribe the origin and characteristics of your condition:Are you involved in any programs or training, which willhave an impact on your ability to use publictransportation? If so, please describe:(OTH)(OTH)(OTH)I have a severe medical condition, which limits my abilityto function. Please describe and note whether yourcondition is temporary or permanent, and if it is episodicin nature (i.e. do you have “good” days or times whenyou can access transportation, and “bad” days when youcannot?)I am dealing with functional losses due to aging. I feel Iam not able to access regular bus service due to thefollowing limitations:Other. My functional limitations do not fit into any of theabove categories. I am unable to use regular bus servicebecause:This condition is temporary permanentGoRaleigh ACCESS ProgramPage 63/18/2016

Please check any of the following Environmental or IndividualFactors which are applicable to your situation:I. ENVIRONMENT:If I am waiting outside at a bus stop, I must have:a bencha shelter nothing additionalWhen crossing a street, I need:curb cuts tactile curb warnings audible signalsaccessible median stripno more than (# ) lanes of trafficI cannot make my way across ground which is:paved or sidewalkgrassygravelhillyMy ability to access transportation is affected by weather which is:warm (above degrees) cold (below degrees)rainyicy windyMy ability to access transportation is dependent on the time of day. Icannot see in: full daylight partial lightdarkness/ semi-darknessMy ability to access stairs is as follows. I can manage:only one or two steps only with a handrail nostepsII. INDIVIDUALThe distance I can travel to and from bus stops is:no more than feetat least five blocksI can wait at a bus stopno more than (# ) minutesat least one hourThe bus stops which I can accessmust be stops for which I have received formal travel trainingmust be only in areas familiar to meGoRaleigh ACCESS ProgramPage 73/18/2016

I travel: aloneboth alone and with a companiononly with an attendant or companion (this does NOTaffect eligibility)If you travel with someone who assists you, does this person assistyou in:Getting to or from bus stopsGetting on or off the busTo help me where I am goingOther (describe):I can cross a street with 2-3 lanes 4-6 lanesI cannot crossList your 5-6 most frequent destinations and how you currentlyget there:DestinationFrequency of travelHow you get therenow:List places you would like to go but cannot currently access:DestinationFrequency DesiredBarriers to youraccessWhich of the following mobility aids do you use? (please check allthat apply)CaneManual WheelchairService animalWhite Cane Powered WheelchairPicture boardWalkerPowered scooter/cartAlphabet boardCrutchesBoarding chairPortable oxygenProsthesisTransfer boardNone of theseOther (describe):GoRaleigh ACCESS ProgramPage 83/18/2016

If you use a manual or powered wheelchair or scooter, what year,make, and model is it?Do you use a manual or powered wheelchair or scooter?YesNoPART B of this application must be filled out by a health care orhuman services professional who is familiar with the applicant’sdisabling condition and/or functional limitation.Your signature on the application authorizes this professional toprovide information to the City of Raleigh regarding youreligibility for ADA services and any needed clarification offunctional limitations due to your disabling condition.In the space provided below, CLEARLY PRINT the name of theprofessional who will be verifying your application, and specifyhis/her position.Name of professional:Professional affiliation (check the appropriate designation):Licensed physicianLicensed physical therapistLicensed occupational therapistLicensed social workerNurse (LPN or RN)Certified psychologistCertified rehabilitation counselorSpeech pathologistVision t/ Hearing specialistMR/DD qualified specialistGoRaleigh ACCESS ProgramPage 93/18/2016

I certify that the information contained in this application iscorrect and authorize the above-named professional to provideverification of my condition and supporting information asneeded:Applicant’s signature:If the applicant was assisted by someone else to complete thisform, please list contact information below:Name:Daytime telephone #:Address:Relationship to Applicant:SIGNATURE:Applicant’s emergency contact (if different from person assisting withapplication:NameDaytime phone:Personal Care Attendant(s):If you require mobility assistance from one or more PersonalCare Attendants, please complete the following information:Personal Care Attendant Name:Address:City: , State: , Zip Code:Telephone #:GoRaleigh ACCESS ProgramPage 103/18/2016