Demand Response Application
INFORMATIONOBTAINEDINTHISCERTIFICATIONPROCESSWILLONLYBE USEDBYTHESOUTHEASTERN REGIONALTRANSITAUTHORITY FORTHE PROVISIONOFTRANSPORTATIONSERVICES. INFORMATION WILLONLYBE SHAREDWITHOTHERTRANSITPROVIDERSTOFACILITATETRAVELIN THOSEAREAS. THEINFORMATIONWILLNOTBEPROVIDEDTOANYOTHER PERSONORAGENCY. (Returncompletedapplicationto:
SRTAAdmin. Offices, 700PleasantStreet,Suite #320,NewBedford,MA 02740)
---PLEASEPRINT---
1. Name:______
(Last) (First)(Middleinitial)
2.Address:______
(Street)(Apt.#)
______
(City/Town)(State)(Zip)
3. MailingAddress(IfDifferent)
______
(Street)(P.O. Box)(City/Town)(State) (Zip)
4.TelephoneNumber: (home) ______
(work) ______
5.DateofBirth:
6.Whatdisabilitypreventsyoufromusingourfixedrouteservice?
Isthisconditiontemporary?
IfYes,expectedlength:
7. Howdoesthisdisabilitypreventyoufromusingfixedrouteservice?
Pleaseexplaincompletely. Useanadditionalsheetifneeded.
8.Arethereanyothereffectsofyourdisabilityofwhichweneedtobeaware?
THEFOLLOWINGINFORMATIONWILLBEUSEDTOENSURETHATTHE APPROPRIATESERVICEISPROVIDEDTOYOUANDTHATANACCURATE ANALYSISOFYOURTRIPREQUESTSCANBEMADEBYTHESOUTHEAST· ERNREGIONALTRANSITAUTHORITY.
9. Doyouuseanyofthefollowingaidstomobility?(Checkallthatapply)
Manualwheelchair ______Powerscooter______Poweredchair______
Cane Walker Crutches Braces Aidedog
10.Pleaseanswerthefollowingquestions:
Canyoutravel200feetwithouttheassistanceofanotherperson?
Yes No Sometimes(explain) ______
Canyoutravel1/4ofamilewithouttheassistanceofanotherperson?
Yes No Sometimes (explain)__
Canyoutravel3/4ofamilewithoutassistanceofanotherperson?
Yes No Sometimes (explain)_
Canyouclimbthree(3)12inchstepswithoutassistance?
Yes No Sometimes (explain)_
CanyouusefixedroutebusesiftheyhavewheelchairliftsIkneelingsteps? Yes__ No _____Sometimes (explain) ______
Canyouwaitoutsidewithoutsupportfortenminutes?
Yes No Sometimes (explain)_
Canyoudealwithunexpectedsituationsorroutines?
Yes No Sometimes (explain)_
Canyoufollowdirectionsorgiverequestedinformation?
Yes No Sometimes (explain)_
Canyoutravelthroughcrowdedterminals?
Yes No Sometimes (explain)__
IHEREBYCERTIFYTHATTHEINFORMATIONGIVEN ABOVEISCORRECT. Signed ______Date_/_/_
INORDERTOALLOW SRTATOEVALUATEYOURREQUEST,PLEASE CONTACTAPHYSICIAN,HEALTHCAREPROFESSIONAL OROTHER PROFESSIONAL TOCONFIRMTHEINFORMATIONYOUHAVEPROVIDED. PLEASEHAVETHEFOLLOWING INFORMATIONPROVIDED TOTHEAU THORITY. ALLQUESTIONSMUSTBEANSWEREDBEFOREADETERMI NATIONCANBEMADE.
THEATTACHEDINFORMATION HASBEENSUBMITTED TOSRTABYTHEAPPLICANT.SRTAASKSTHATYOUPROVIDEINFORMATIONRE GARDINGHIS/HERDISABILITY ANDITSIMPACTUPONHIS/HERABILITY TOUTILIZEOURTRANSITSERVICES.FEDERALLAWREQUIRESTHAT SRTAPROVIDEPARATRANSITSERVICESTOPERSONSWHOCANNOT UTILIZEAVAILABLEFIXEDROUTESERVICES. APERSONMUSTHAVE ANACTUALPHYSICAL ORMENTALFUNCTIONAL LIMITATIONTHAT DOESNOTALLOW THEMTOUSEREGULARACCESSIBLEPUBLIC TRANSPORTATION. AMEDICALDIAGNOSISOFANILLNESS ORMEDI CALCONDITION DOESNOTAUTOMATICALLY MAKETHEAPPLICANT ELIGIBLE FORSERVICE. THEINFORMATIONTHATYOUPROVIDEWILL ALLOWUSTOMAKE ANAPPROPRIATEEVALUATIONOFTHISREQUEST ANDITSAPPLICATION TOSPECIFICTRIPREQUESTS.
THANKYOUFOR YOURCOOPERATIONINTHISMATTER.
1.Capacityinwhichyouknowtheapplicant:
2. Conditionpreventingorlimitingtheapplicantfromusingregularfixedroute service:(DIAGNOSIS: CERTIFIER MUST COMPLETE!)
Please fill in: ______
3. Istheconditiontemporary?YesINoExpectedduration:until_/_/_
4.Ifthepersonhasadisabilityeffectingmobilitycantheperson: Travel200feetwithoutassistance?Yes No-- Travel1/4milewithoutassistance?Yes No--
Travel3/4milewithoutassistance?Yes No--
Climbthree(3)12inchstepswithoutassistance?Yes___No Waitoutsidewithoutsupportfor10minutes?Yes______No
IF'YES"TOANYOFTHEABOVEQUESTIONS:Cantheapplicantuse
regularfixedrouteserviceifthatservicehaswheelchairliftsorkneelingsteps?
Yes No_
5.DoestheclientrequireaPersonalCareAttendant (PCA)whentraveling?
YesINo(circleone)
6. Doestheclientuseanyofthefollowingaidstomobility?(Checkallthatapply)
Manual wheelchair ____Power scooter ___Powered chair____
Cane__ Walker__ Crutches__ Braces ___ Aide dog ___
7.IsthepersoneffectedbycertainweatherIclimateconditions orgeographical featureswhichpreventshim/herfromusingfixedrouteservice? WEATHER:Cold/Ice_____HeatIHumidity _
PHYSICALTERRAIN:(SPECIFY) __
8.Ifthepersonhasavisualimpairment:
Visualacuitywithbestcorrection:
RightEye______Left Eye __BothEyes _
Visualfields:
RightEye______LeftEye______BothEyes ___
9. Ifthepersonhasacognitivedisability: Isthepersonableto: Giveaddressesandtelephonenumbersuponrequest?
YesNo
Recognizeadestinationorlandmark?
YesNo
Dealwithunexpectedsituationsorunexpectedchangeinroutine?
YesNo
Askfor,understandandfollowdirections?
YesNo
Safelyandeffectivelytravelthroughcrowdedand/orcomplexfacilities?
YesNo
10.ArethereanyotherproblemsofwhichSRTAshouldbeaware?
(NOTE:FAILURETO ANSWERTHESEQUESTIONSMAYDELAYORJEOPARDIZETHECERTIFICA· TIONFORSERVICE.)
Certifier'sName(PleasePrint): ______
OfficeAddress:
OfficePhoneNumber: ______License Number/State: ______
Signature: Title:__