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GREATER HARTFORD TRANSIT DISTRICT
ADA (Americans with Disabilities Act)
PARATRANSIT APPLICATION

ALL QUESTIONS MUST BE COMPLETELY ANSWERED
INCOMPLETE APPLICATIONS WILL BE RETURNED

***UPON RECEIPT OF YOUR COMPLETED APPLICATION,
WE WILL CONTACT YOU TO SET UP A PERSONAL INTERVIEW***

GENERAL INFORMATION (Fields marked with an asterisk, *, are required)

Last Name
 *
First Name
 *
Street Address
*
Apt. #/Bldg. #
City
 *
State
 *
Zip
 *
Is this a Licensed Nursing Care Facility?
yes no
If yes, Name of Facility
Is this a temporary residence?
yes no
Telephone (daytime)
 *
Telephone (evening)
TDD/Relay# (If applicable)
Date of Birth
Sex

Male Female
Do you need information given in accessible formats?
yes no
How did you hear about our services?
Are you eligible to use medical or other transportation services?
(e.g., Medicaid, Social Services, etc.)
 yes no don't know
Please give us the name and telephone number of someone we can call in an emergency or if we are unable to reach you at your regular number:
Name
Relationship
Telephone (Home)
Telephone (Work)
Agency (If applicable)
If someone assisted you in completing this application, please provide us with that person’s name and telephone number below:
Name
Relationship
Telephone
Agency (If applicable)

 
DESCRIBE YOUR PUBLIC BUS EXPERIENCE
1. Do you ride the public city bus (CTTransit)?
yes no sometimes
2. When was the last time you used the public city bus (CTTransit) service?

3. Complete the following by checking the response that you believe describes your ability to ride the public city buses (CTTransit). You may check more than one:

I can always use the public city bus (CTTransit) with little or no difficulty.

I have a disability that allows me to use the public city bus (CTTransit) on days when I’m feeling well, but on “bad days” I cannot make it to the bus stop or get on the bus.

I have a temporary disability that prevents me from using the public city bus (CTTransit). I will need paratransit services only until I recover.

I can never get to the public city bus (CTTransit) stop by myself due to the severity of my disability.

I have a disability that prevents me from remembering and understanding all I have to do to use the public city bus (CTTransit). I may be able to learn with training.

I have a visual disability that prevents me from getting to and from the public city bus (CTTransit) stop.

I cannot use the public city bus (CTTransit) for some trips because I have not learned the route, or there are some other barriers that prevent me from using the public city bus (CTTransit) .

 

INFORMATION ABOUT YOUR FUNCTIONAL ABILITY

For each statement, check one answer. Your answer should be based on how you feel most of the time under normal circumstances, and whether you can perform this activity.
4. I can cross the street if there are curb cuts.
Always Sometimes Never

5. I can travel up/down a gradual hill in good weather conditions.
 Always Sometimes Never

6. I can find my way to the public city bus (CTTransit) stop if someone shows me once.
 Always Sometimes Never

7. I am able to wait for 10 minutes at a public city bus (CTTransit) stop that does not have seats and a shelter.
 Always Sometimes Never

8. I am able to ask for, understand, and follow directions.
 Always Sometimes Never

9. I am able to detect curbs, ramps, and other drop off areas.
 Always Sometimes Never

Answer the following questions by checking all that apply.

10. What barriers in your surroundings would make it difficult for you to use the public city bus (CTTransit)?
Lack of curb cuts No Sidewalks Steep hill
Sidewalks are in poor condition Busy streets I must cross
No crosswalks at street corners
Other

11. Can you get on and off a public city bus (CTTransit)?
Yes, I can climb steps I probably could with instruction
Yes, I can use the lift and/or ramp
No (Please explain)

12. Is there any medication that affects your daily travel?

TRAVEL TRAINING INFORMATION

I could use the public city buses (CTTransit) if I had general knowledge
about routes and times. Yes No Sometimes

Travel Training is a free service, which assists people with disabilities to
learn how to ride and use the public city bus (CTTransit) service.

Would you like more information? Yes No

INFORMATION ABOUT YOUR DISABILITY

13. What type of disability prevents you from using the public city bus (CTTransit) system? Check all that apply:
Physical Visual Cognitive Mental Health Hearing None
Other

Identify Disability by Name(s)

Please describe your disability in detail.

14. Is this condition temporary? Yes No
If yes, expected duration?

15. Do you require the assistance of a personal care attendant?
No, I do not require an attendant
 Yes, I do require an attendant
 Sometimes, because of my disability there are times when I need assistance

16. Do you use any of the following devices? Check all that apply:
*Manual Wheelchair * Power Scooter *Electric Wheelchair Cane Walker White Cane
Braces Oxygen Tank Crutches Communication Board Service Animal None
Cart Other

* ADA regulations defines a common wheelchair as any device that has three or four-wheels operated manually or powered. It should not exceed 30 inches in width, 48 inches in length, and 600 pounds when occupied.

AUTHORIZATION TO OBTAIN
PHYSICIAN OR OTHER PROFESSIONAL VERIFICATION

In order to evaluate your request, it may be necessary to contact your physician or other professional to confirm the information you have provided.  Please complete the following information and authorization form.

Physician   Health Care Professional   Rehabilitation Professional
Professional’s Name
 *
Agency
Office Address
 *
City
 *
State
 *
Zip
Phone
 *
Applicant’s Name
*
Date of Birth
 *
Office Fax
 *

Definition of ADA Regulations 

Any person with a disability who is unable, as a result of a physical or mental impairment, and without the assistance of another individual, (except the operator of a wheelchair lift) to board, ride, or disembark from any public city bus.

Any person with a disability who has a specific impairment-related condition which prevents them from traveling to or from a bus stop on the public city bus system. 

Architectural and environmental barriers such as distance, terrain or weather; do not, standing alone, form a basis for eligibility.  However, a person may be eligible if the interaction of the disability and barriers prevent the person from traveling to or from the public city bus stop.

APPLICANT’S CERTIFICATION 

Please read the following paragraph.
You will be asked to sign this form at your interview. 

I understand that the purpose of this application is to determine if there are times when I cannot use the public city buses (CTTransit) and must therefore use the ADA Paratransit Service.  I understand that any information about my disability contained in this application will be kept confidential and shared only with professionals involved in providing this service.  I certify that, to the best of my knowledge, the information in this application is true and correct.  I understand that providing false or misleading information may result in the agency re-evaluating my eligibility. 

If you have any questions about the application or the service, please call  (860) 247.5329, extension 3005.  Please be sure to complete all sections of the application.  An incomplete application will lead to a delay in our ability to serve you.