ADA Paratransit Application

1. Last Name *
2. First Name *
3. Middle Initial
4.  
5. Male/Female * Male Female Prefer Not to Answer
6. Date of Birth *
7. Street Address *
8.  
9. Building No./Apt. No.
10. Apartment Name
11. City/Town *
12. State *
13. Zip *
14. Home Phone *
15. Work Phone
16. Cell Phone
17. Emergency Contact Name *
18. Emergency Phone *
19. Email
20.  
21. If you have a current SARTA ADA Paratransit Code number, please provide the number:

I understand the purpose of this evaluation form is to determine my eligibility for Paratransit Service.  I understand the information about my disability contained in this application will be kept confidential and shared only with professionals involved in evaluating my eligibility.

I hereby authorize my medical representative to release any and all information regarding my medical condition to SARTA. 

I understand that providing false or misleading information could result in my eligibility status being revoked. 

1. Click below to approve the applicant release.  *

   1. approved
   2. not approved

Please read the following statements and respond whether you strongly agree, agree, disagree or strongly disagree as to whether or not these statments fit your ability to use SARTA's Fixed Route bus service without assistance.   

1. I can use SARTA's Fixed Route bus services for some trips, but not other times because there are barriers that prevent me from using the system. *

   1. Strongly Agree
   2. Agree
   3. Neutral
   4. Disagree
   5. Strongly Disagree
   6. N/A
2.  
3. I use the bus frequently.

   1. Strongly Agree
   2. Agree
   3. Neutral
   4. Disagree
   5. Strongly Disagree
   6. N/A
4.  
5. I have difficulty understanding and remembering all of the things that I would have to do to find my way to and from the bus.

   1. Strongly Agree
   2. Agree
   3. Neutral
   4. Disagree
   5. Strongly Disagree
   6. N/A
6.  
7. I believe I could learn to ride the bus, if I were taught.

   1. Strongly Agree
   2. Agree
   3. Neutral
   4. Disagree
   5. Strongly Disagree
   6. N/A
8.  
9. I have difficulty or cannot climb stairs and can only board a SARTA vehicle if it has a lift.

   1. Strongly Agree
   2. Agree
   3. Neutral
   4. Disagree
   5. Strongly Disagree
   6. N/A
10.  
11. I have a visual disability, which prevents me from getting to and from the bus, even with training.

    1. Strongly Agree
    2. Agree
    3. Neutral
    4. Disagree
    5. Strongly Disagree
    6. N/A
12.  
13.  
14. The severity of my disability can change from day-to-day. I can only ride the Fixed Route bus when I am feeling well.

    1. Strongly Agree
    2. Agree
    3. Neutral
    4. Disagree
    5. Strongly Disagree
    6. N/A
15.  
16. I can never use the bus by myself

    1. Strongly Agree
    2. Agree
    3. Neutral
    4. Disagree
    5. Strongly Disagree
    6. N/A
17.  
18. I can get to and from the bus if the distance is not too great and the route is barrier-free.

    1. Strongly Agree
    2. Agree
    3. Neutral
    4. Disagree
    5. Strongly Disagree
    6. N/A
19. I am not able to use the bus due to my disability.

    1. Strongly Agree
    2. Agree
    3. Neutral
    4. Disagree
    5. Strongly Disagree
    6. N/A
20. Please explain in detail your disability that prevents you from using SARTA's Fixed Route bus service.

Please list your 3-4 most frequent destinations and how you get there now.

 Note: SARTA may not be able to provide transportation if the lift and the vehicle cannot accommodate the mobility device or if the weight of you and your mobility device exceeds 600 pounds."  

1. Name of Location 1
2. Destination Address 1
3. Destination City 1
4.  
5. Frequency of Travel 1
6. How you currently get there? 1
7.  
8.  
9. Name of Location 2
10. Destination Address 2
11. Destination City 2
12.  
13. Frequency of Travel 2
14. How you currently get there? 2
15.  
16.  
17. Name of Location 3
18. Destination Address 3
19. Destination City 3
20.  
21. Frequency of Travel 3
22. How you currently get there? 3
23.  
24.  
25. Name of Location 4
26. Destination Address 4
27. Destination City 4
28.  
29. Frequency of Travel 4
30. How you currently get there? 4
31.  
32. Does your health condition/disability require you to use Paratransit Service:

    1. Seasonal (Nov.-Apr.)
    2. Permanently
    3. Temporarily
33. If temporarily, for how long?

    1. Week(s)
    2. Month(s)
    3. Year(s)
34. Please indicate the primary mobility aid you use when traveling in the community: Support Cane Long White Cane Service Animal Hearing Aid Oxygen Tank Leg Brace Crutches Walker Prosthesis Hearing Device Picture Board Alphabet Board Powered Wheelchair Manual Wheelchair Scooter
35. Please indicate any other mobility aids that you use that are not avaible in the list above.
36. Have you ever had a seizure?

    1. yes
    2. no
37. If yes, what type and how often?
38. Are your seizures controlled with medications?

    1. yes
    2. no
39. Do you require a Personal Care Attendant (PCA)? A PCA is a person who will assist you to and from the bus?

    1. yes
    2. no
40. Are you able to be left unattended?

    1. yes
    2. no

1. Have you ever used SARTA's bus services? *

   1. yes
   2. no
2. Does your physical condition change from day-to-day, to the point that it may be difficult to use bus services? *

   1. Yes, my condition is good some days and bad others
   2. No, my condition does not change from day-to-day
3. On days when your physical condition is GOOD, can you, on your own, or using a mobility aid:  *

   1. Get to the curb in front of your house
   2. Travel up to one (1) block
   3. Travel up to (4) blocks
   4. Travel up to (6) blocks
   5. Cannot travel outside your house.
4. If you cannot travel outside your house. Please Explain.
5. On days when your physical condition is BAD, can you, on your own, or using a mobility aid:  *

   1. Get to the curb in front of your house
   2. Travel up to one (1) block
   3. Travel up to (4) blocks
   4. Travel up to (6) blocks
   5. Cannot travel outside your house.
6. If you cannot travel outside your house. Please explain
7. Does the weather have an effect on your ability to use bus services? *

   1. yes
   2. no
8. Are you currently using SARTA's bus services? *

   1. yes
   2. no
9. If you answered yes, what routes are you taking:
10. Can you transfer from one bus to another? *

    1. yes
    2. no
11. If no, please explain:
12. Are you able to, on your own, use the telephone to obtain bus information? *

    1. yes
    2. no
13. If no, please explain 1
14. Are you able to follow written or oral instructions to use bus services? *

    1. yes
    2. no
15. If no, please explain 2
16. Can you, without assistance of another person, get to or from the bus stop nearest your home? *

    1. yes
    2. no
17. If no, please explain 3
18. Can you wait ten (10) minutes at a bus stop that has a seat and a shelter? *

    1. yes
    2. no
19. If no, please explain 4
20. Can you wait ten (10) minutes at a bus stop that does NOT have a seat and a shelter? *

    1. yes
    2. no
21. If no, please explain 5
22. Are you able to get on and off a bus if it had a mobility device lift? *

    1. yes
    2. no
23. If no, please explain 6
24. Are you able to follow written/oral instructions to pay your bus fare? *

    1. yes
    2. no
25. If no, please explain 7
26. Are you able to recognize a destination or landmark? *

    1. yes
    2. no
27. If no, please explain 8
28. Can you cross a street? *

    1. yes
    2. no
29. If no, please explain 9
30. Can you balance while seated? *

    1. yes
    2. no
31. If no, please explain 10
32. Can you grip handles and railings? *

    1. yes
    2. no
33. If no, please explain 11
34. Can you climb a 12-inch step? *

    1. yes
    2. no
35. If no, please explain 12

The Medical Certification form must be received by SARTA before the application is considered to be complete.  In any event, the Medical Certification must be submitted no later than 30 days after the submission of the online application.  Only upon receipt of the Medical Certification completed and signed by a licensed physician will SARTA begin the revivew of the application.  SARTA provides a determination of eligibility within 21 days of receiving the Medical Verification form. 

Applicants can obtain the form by clicking on the medical assessment link on the top of this page or referring back to the Proline section of the website and downloading the complete ADA Application form.  The form is also available by contacting SARTA's Proline Service at 330-455-2292.