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Appendix B - San Francisco Nine-County Bay Area Application for ADA Complementary Paratransit Service

The Americans With Disabilities Act of 1990 (ADA) is federal legislation prohibiting discrimination against people with disabilities. One of the overriding principles of the ADA is to ensure that all people have equal access to public transportation. In order to ensure this access, public transit vehicles and facilities are required to be fully accessible and usable by persons with disabilities. For people who are unable, due to a physical or mental disability (including mobility or cognitive impairments) to independently use the public fixed-route transportation (bus, light rail [streetcar], BART train, etc.), paratransit services must be made available.

If you believe that you have a disability (including mobility or cognitive impairments), which prevents you from independently using public fixed-route transportation facilities and/or vehicles, please complete this regional application form and return it to the transit agency serving your community. The questions on this application are designed to provide assistance in determining your functional abilities.

Your completed application will be reviewed and a decision regarding your eligibility for paratransit services made within 21 days. You may be found eligible for paratransit services for all of your travel needs, eligible (based on your abilities) for some requests but not for others, or you may be found capable of using the fixed-route facilities and vehicles. If you disagree with the decision made regarding your eligibility status, you may appeal the decision. It is possible that upon review of your application, you may be asked to provide additional information. This may include contacting a licensed professional familiar with your functional abilities, a phone or personal interview, or a physical or cognitive functional evaluation.

If you are determined ADA eligible you will be certified to use paratransit, based on your travel eligibility, throughout the nine-county San Francisco Bay Area. The following page lists the Bay Area public transit operators who are participants in the regional ADA Paratransit Eligibility Program.

All information regarding the certification process and paratransit services will be made available in accessible formats (i.e. Large Print, Braille, Audio Tape, other) upon request.

All information requested throughout the certification process will be kept confidential.

Revised 1/95

The following Bay Area fixed-route transit operators are participants in the regional ADAParatransit Eligibility Program. AC Transit
BART
City of Benicia County Connection (Central Contra Costa Transit Authority)
Cities of Fairfield / Suisun City
Golden Gate Bridge, Highway and Transit District
LAVTA (Livermore-Amador Valley Transit Authority)
MCTD (Marin County Transit District)
Muni (San Francisco Municipal Railway)
City of Petaluma
SamTrans (San Mateo County Transit District)
Santa Rosa CityBus
Solano Transportation Authority
Sonoma County Transit
TA(Transportation Agency, Santa Clara County)
Tri Delta (Eastern Contra Costa Transit Authority)
Union City Transit
City of Vacaville
Vallejo Transit
The V.I.N.E. and Napa Valley Transit
WestCAT (Western Contra County Transit Authority)

It is important to complete all parts of this form -- type or print, please. Applications that are not complete or clearly written will be returned, which will delay the eligibility determination process.

Name (first, middle, last):
__________________________________________________________________
Home Address: ______________________________________ Apt.#: ______________
City: ____________________________________________ ZIP: _______________
Mailing Address (if different from Home):_________________________ Apt.#: __________
City: _____________________________________________ ZIP: ________________
Daytime Phone: (____)_________________TDD/TTY: (____)______________________
Evening Phone: (____)___________________
Birth Date: ____/____/____/
Female ____ Male _____

Primary Language: Please check: ____English _____Other (please specify) ________________________________

Do you need this application and future written information provided to you in an accessible format? ___Yes ____ No (If yes, what format do you prefer):

___ Diskette ____ Audio Tape ____ Braille ____ Large Print Other____________

If assistance was provided in filling out this form, please indicate by whom:

Name: ____________________________ Phone: (______)__________________
Relationship: _______________________________
Please indicate if this person should be contacted directly if additional information is requested. ___Yes ___No

Emergency Contact Person:
Name:__________________________ Day Phone: (______)_________________
Relationship: _____________________ Eve. Phone: (______)_________________
Please answer the following questions in detail -- your specific answers to the questions will help us in determining your eligibility.

1
a. What is your disability or health related condition that prevents you from using public transit?

b. Explain HOW your disability or health related condition prevents you from independently using the public transit services (BART, bus, light rail [streetcar]).

c. Are the conditions you described permanent ______or temporary _____? (Please check one.) If temporary, how long do you expect this to continue?________________

2. How do you currently travel to your most frequent destinations? Check all that apply:
_____ Public Buses
_____ Someone drives me
_____ Drive myself
_____ Paratransit
_____ Taxi
_____ Ferry
_____ BART
_____ Light Rail [streetcar]
Other:_________________

3. Does your health condition or transportation disability change from day to day in a way that affects your ability to use public buses, BART, or light rail [streetcars]?
___ Yes, good on some days, bad on others. ___ No, doesn't change. ___ Don't know. If yes or don't know is selected, explain why:

For questions 4 through 12, please indicate whether you are independently able to perform the following functions. ALL no or sometimes answers must be accompanied by an explanation or the application will be considered incomplete.

4. Are you able to understand directions needed to complete a trip? (This doesn't refer to being unaccustomed to the English language.) ___ Yes ___ No ___ Sometimes
If no or sometimes is selected, explain why:

5. Are you able to identify the correct public transit stop? ___ Yes ___ No ___ Sometimes
If no or sometimes is selected, explain why:

6. Are you able to identify the correct public transit vehicle? ___ Yes ___ No ___ Sometimes
If no or sometimes is selected, explain why:

7. Are you able to get to and from the nearest public transit stop? ___ Yes ___ No ___ Sometimes
If no or sometimes is selected, explain why:

Note how many city blocks you can independently travel: _____________________

8. Are you able to wait at least 15 minutes at a public transit stop? ___ Yes ___ No ___ Sometimes
If no or sometimes is selected, explain why:

Could you wait longer than 15 minutes?

___Yes ___No ___Sometimes

If so, how long? _______________(minutes)
Could you wait if there were a seat or bus shelter?___ Yes ___ No

___ Sometimes

9. Are you able to get on and off the following public transit vehicle without assistance?
Public Bus
____ Yes ____ No ____ Sometimes
BART Light Rail [Streetcar]
____ Yes ____ No ____ Sometimes

If no or sometimes is selected, explain why:

10. Are you able to get on or off a public transit bus if it has a lift or if the front of the bus is lowered?
____ Yes
____ No
____ Sometimes
____ Don't know, never tried it.
If no or sometimes is selected, explain why:

11. Are you able to grasp handles or railings, coins or tickets while boarding or exiting the transit vehicle?
____ Yes
____ No
____ Sometimes

If no or sometimes is selected, explain why:

12. Are you able to maintain balance and tolerate public transit vehicle movement when seated?
____ Yes
____ No
____ Sometimes

If no or sometimes is selected, explain why:

13. Have you ever had any training or instruction to learn how to use the public transit (BART, bus, light rail [streetcars])?
____Yes
____ No

If yes is selected, where and when did you receive this training?

14. Is the public transit you need accessible?
____ Yes
____ No
____ Sometimes

____ Don't know, never tried it. If no or sometimes is selected, explain in what way is it not accessible?

15. Do you use any of the following mobility aids or specialized equipment? Check all that apply.
[____] Cane
[____] Power Chair
[____] Communication Board
[____] White Cane
[____] Large Power Chair
[____] Service Animal
[____] Walker
[____] Power Scooter (3-wheeler)
[____] Other Aid____________
[____] Crutches
[____] Manual Chair
[____] Leg Braces

16. Does a personal care attendant accompany you when you travel outside your home (for example, to push your wheelchair, carry oxygen, etc.)?
____ Yes
____ No
____ Sometimes

17. Do you currently use paratransit service? (Please check one):
____ Yes
____ No
____ Sometimes
If yes or sometimes is selected, when do you use paratransit service?

Please give paratransit provider's name: ____________________________________

I certify that the information in this application is true and correct. I understand that falsification of the information may result in denial of service. I understand all information will be kept confidential, and only the information required to provide the services I request will be disclosed to those who perform the services. I understand that it may be necessary to contact a professional familiar with my functional abilities to use public transit in order to assist in the determination of eligibility.

Applicant's signature __________________________________ Date ________________

PROFESSIONALAUTHORIZATION

I hereby authorize (Enter the name, address and phone number of the licensed professional familiar with your disability or health related condition): _______________________________________________________________________________ to release to my local public transit agency necessary information about my disability in order to verify my eligibility for paratransit services. The information released will be used solely to determine my eligibility. I realize that I have the right to receive a copy of this authorization.

I understand that I may revoke this authorization at anytime.

Enter the name of applicant and the date signed:

_____________________________________________________ Date__________________

Applicant's signature:

_____________________________________________________

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