PART 1 GENERAL INFORMATION

Basic Information.

First Name
Last Name
Street Address 1
Street Address 2
City
State	State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip
Date of Birth
Primary Phone
Secondary Phone

Social Security Number

If Someone Helped you in completing this form please identify them below:

Select a Stored Contact:	None Saved
Name
Phone Number
Relationship:
Email:

Do you need this information and material given to you in any of the following ways? (check all that you need)
SpanishLarge PrintAudio TapeBraille Other:

Please give us the name and telephone number of someone we can call in an emergency

Select a Stored Contact:	None Saved
Name
Phone Number
Relationship:
Email:

PART 2 APPLICANT’S CERTIFICATION

Please indicate below the reasons why you are seeking ADA paratransit eligibility (check all that apply) I can use county fixed route buses sometimes.
I can use county fixed route buses sometimes, but only if they are equipped with wheelchair lifts.
Because of my disability, I can never use the LAKETRAN county fixed route bus service.

I understand that the purpose of this evaluation form is to determine if there are times when I cannot use the county fixed route bus service provided by Laketran and must therefore use the complementary bus service. I understand that the information about my disability contained in this application will be kept confidential and shared only with professionals involved in evaluating my eligibility. I certify that, to the best of my knowledge, the information in this evaluation form is true and correct. I understand that providing false or misleading information could result in my eligibility status being re‐examined as well as other actions by Laketran.

Applicant's signature:		Date:
	(Type your full name.)

PART 3 INFORMATION ABOUT THE APPLICANT’S DISABILITY

What type(s) of disability prevents you from using the county fixed route bus service? (check all that apply)? physical disabilityvisual impairment/blindness
developmental disabilitymental illness
othernone

1. Please describe your disability in more detail:

2. Has your health condition or transportation disability changed within the past 2 years?(Please Describe)

3. Please indicate below if you use any of the following mobility aids or equipment(check all that apply)?

canelong white cane
leg bracescrutches
walkerpicture board
alphabet boardmanual chair
powered chairpowered scooter/cart
I don't use any of the above aids or equipment

3a. I use another mobility aids or equipment. (Please Describe)

3b. I use a service animal. (Please Describe)

3c. Size and weight of powered scooter/cart.

PART 4 MEDICAL VERIFICATION

4. Do you require the assistance of a Personal Care Attendant (PCA) (someone who helps you with daily life functions)? I need assistance when I travel with Mobility.
I need assistance when I travel with transfers.

4a. Other. (Please describe)

5. Is the disability described above temporary or permanent? Temporary, I expect it to last for another month.
Permanent
I don't know

PART 5 QUESTIONS ABOUT USING COUNTY FIXED ROUTE BUSES

6. Do you have a Golden Buckeye Card or Medicare Card for reduced fares on public bus services? YesNo

7. I typically use the county fixed route buses times a week.

(input 0 if you never use county fixed route)

7b. I used county fixed route buses, but stopped because .

8. Is there something that might help you to ride the buses (check all that apply)? YES, route and schedule informationYES, learning to use the buses
YES, being able to get buses with liftsYES, a communications aid
YES, if buses were closer to where I live and where I need to go.NO, none of these would help

9. Can you ask for and follow written or oral instructions to use the county fixed route buses? YesNo
SometimesI don't know becasue I have never tried to use the buses

9a. If NO or SOMETIMES, please check all that apply I get too confused and might get lost
No
Other people cannot understand me
I probably could with instruction

9b. Other:

10. Using a mobility aid or on your own, how far can you travel?I cannot travel outside my house/apartment
I can get to the curb in front of my house/apartment
I can travel up to three blocks (¼ mile)
I can travel up to six blocks (½ mile)
I can travel up to nine blocks (¾ mile)

11. Can you wait up to 30 minutes for a county bus at a bus stop? YES
YES, but only if the stop has a bench or shelter
YES, but I don't like to wait that long
NO

11a. If no please explain.

12. Can you get on and off a county bus? (All Laketran buses have wheelchair‐ramps and a "kneeler" which lowers the height of the steps. Passengers who find the steps to be too high may enter and exit the bus by using the bus ramp.)

YesNo
SometimesI don't know becasue I have never tried

12a. If No Or Sometimes please check al that apply? Only if the bus has a wheelchair ramp
I cannot climb the stairs
I don't want to use the ramp
I probably could with instruction

12b. Other:

13. If you are able to get on and off county fixed route buses, do you know where to get off the bus or can you find out by yourself? (Only answer if you answered YES to #12)

YesNo
SometimesI don't know becasue I have never tried

13a. If No Or Sometimes please check al that apply? I get confused and can't remember where I am going
I can if the driver calls out the stops
I don't want to use the ramp
I probably could with training

13b. Other

14. Are there any other conditions which limit your ability to use the county fixed route buses?

PART 6 CURRENT TRAVEL INFORMATION

If you are presently utilizing our Dial‐a‐Ride service, please list the three trips that you will most frequently make using the complementary bus service.

From:	To:
Select a Stored Location: None Saved Address City Zip code	Select a Stored Location: None Saved Address City Zip code
Select a Stored Location: None Saved Address City Zip code	Select a Stored Location: None Saved Address City Zip code
Select a Stored Location: None Saved Address City Zip code	Select a Stored Location: None Saved Address City Zip code

PART 7 INFORMATION ABOUT TRAVEL TRAINING

Travel training is personal (one‐on‐one) instruction that teaches an individual how to use county fixed route buses.

16. Have you ever had any personal instruction to use county fixed route buses?

NO, I have not received any personal instruction.
YES, I received personal instruction through an agency.
YES, I received personal instruction from a friend/relative.

16a. Name of Agency

17. Indicate below all of the skills you learned from your personal training:to travel to and from the bus stops
to cross the streets
to ride the on routes
reading the bus schedules and planning my trips

17a. What routes did you learn to ride?

17b. Other skills learned:

18. Is there anything else you would like to tell us about your disability or impairment?