Application for Certification of ADA Paratransit Eligibility

Dear Customer:

Thank you for inquiring about applying for Salisbury Transit System ADA
Paratransit eligibility. If you have a disability or health condition that prevents you from sometimes or always using Salisbury Transit fixed route bus service, you may be eligible for ADA Paratransit. Enclosed is a copy of an Application for
Certification of ADA Paratransit Eligibility, as well as information outlining the
certification process.

Please read these following carefully before completing the application.

The Americans with Disabilities Act (ADA) of 1990 requires public transit
agencies to provide Paratransit service to people with disabilities who cannot
access the regular fixed route bus service due to their disability or functional
limitation. All of Salisbury Transit buses are equipped with ramps and are
accessible to individuals with disabilities.

ADA Paratransit is a service provided to individuals who are unable to use fixed route bus service because of a disability or functional limitation. An inability to
use fixed-route bus service may include being unable to travel to or from bus
stops, board or exit buses or understand how to ride and use the bus system.

A disability does not guarantee eligibility for ADA Paratransit. Your disability must impact you ability to board, ride and exit a fixed route bus.

There are three types of eligibility:

Conditional Temporary: You are able to use the fixed route bus sometimes and need Paratransit sometimes. The functional limitation is expected to improve.
Conditional Permanent: you are able to use the fixed route bus sometimes and need Paratransit sometimes. The functional limitation will not improve and may become worse.
Unconditional: You cannot use the fixed route bus due to functional limitation

To enable us to accurately determine your eligibility for this service, please
complete the enclosed application as completely and accurately as possible.
The questions are meant to determine the circumstances under which you can use fixed route or Paratransit services.

If you need assistance completing the form, or have any questions, please contact the Salisbury Transit office at 704-638-5252. Upon request, this letter and application is available in large print, and other alternative formats.
After you have completed “Part A” of this application, please have a licensed
health care or rehabilitation professional complete “Part B” of this application and sign the last page. If any sections are left blank, the application will be
returned to you. The information you provide in this application is confidential.

Please do not attach medical documentation or information to this application. You may bring the medical information with you when you have your interview.

Within a few days of receiving your completed application; you will be contacted by telephone to schedule an in-person interview to determine your abilities to use Salisbury Transit fixed-route service. If you need transportation to the interview, we will provide transportation at no cost.

Completed application will be processed within 21 days of receipt. You will then
be notified in writing of your eligibility status. If additional time is required to
complete the evaluation and determination, you will be given temporary eligibility.

If we determine that you are able to use Salisbury Transit fixed route bus service, and are therefore ineligible for ADA Paratransit, we will notify you of the reason(s) for this determination. You may appeal this decision in writing. Appeals will be accepted within 60 days from the date on the eligibility determination letter.

However, ADA Paratransit service will not be provided during the appeal process, unless the appeal process cannot be concluded within 30 days. Eligibility for ADA Paratransit is granted for a period up to three (3) years, regardless of the permanence or temporary nature of the functional limitations.

This application should only be completed if you have a disability or health condition that prevents you from sometimes or always using Salisbury Transit fixed route bus service. Persons completing this application will be considered for ADA Paratransit.

Information about disability or health condition will be kept strictly confidential.

PART A (This section must be completed by all applicants)

Name *

First Name Middle Initial Last Name

E-mail

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Same as Mailing Address? *

Yes No

Mailing Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number (daytime) *

Area Code Phone Number

Phone Number (evening)

Area Code Phone Number

Name of Person Assisting:

First Name Last Name

Has someone assisted you with completing this application? *

Yes No

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Relationship to applicant

Phone Number

Area Code Phone Number

Agency

In case of emergency:

Please provide pertinent information for two people ADA
Paratransit can contact. This can be a friend, relative or support professional familiar with your disability.

Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Relationship to Applicant *

Work Phone *

Area Code Phone Number

Home Phone *

Area Code Phone Number

Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Relationship to Applicant *

Work Phone *

Area Code Phone Number

Home Phone *

Area Code Phone Number

1. What is the disability or health condition that prevents you from using SalisburyTransit fixed route buses? Please describe all disabilities or health conditions that affect your travel. *

2. How does this disability or health condition prevents you from using SalisburyTransit fixed route service? Please explain completely. Use additional sheets if needed. *

3. Do you use any of the following mobility aids? (check all that apply) *

4. Do you ever need to bring someone else with you to help you when you travel? (Example: “a personal assistant” or “personal attendant”) *

No Yes, Always Yes, Sometimes

Assistant Name

First Name Last Name

Assistant Phone

Area Code Phone Number

Assistant Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

5. Without the help of someone else can you ...

Request and understand written or spoken instructions? *