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Sunday , May , 28 , 2017
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[Zia Therapy Center, Inc.]

“Zia”

“Ztrans”

ADA PARA-TRANSIT APPLICATION

 

In compliance with the Americans with Disabilities Act (ADA) of 1990, Ztrans provides ADA Complementary Para-transit Service to individuals with a disability who are traveling in an area served by Ztrans, but who cannot use the regular fixed-route bus service.  This application is intended to determine when and under what circumstances the applicant can use regular fixed-route bus service and when ADA Complementary Para-transit Service is required.

 

INSTRUCTIONS FOR COMPLETING THIS APPLICATION

 

The applicant (or someone assisting the applicant) must complete PARTS 1-7. A licensed professional must complete and sign PART 8 – PROFESSIONAL VERIFICATION, pages 8-9.

 

All applicants, whether new or being recertified, must complete a new application.  The ADA Complementary Para-transit certification process may involve a personal Functional Assessment to determine if the applicant can use the regular fixed-route bus service. Ztrans will pay for the functional assessment as well as provide transportation to and from the evaluation, if necessary.  All questions must be answered. Incomplete applications will be returned. If you have any questions or need assistance in completing this application, please call Ztrans at (575) 439-4971.

 

NOTE:  PROCESSING OF THIS APPLICATION MAY TAKE UP TO 21 DAYS

WHEN COMPLETED, PLEASE RETURN THIS APPLICATION TO:

Ztrans Director

Zia Therapy Center, Inc.

900 First Street

Alamogordo, NM  88310

 

 

 

DO NOT WRITE IN THIS SPACE

New Application:_____________________              Recertification:__________________________

Date Received:_______________________             Approved: ________________ Date:________

Reviewed By:________________________             Denied: __________________  Date:________

Bill Code:___________________________              Third Party Review: ________  Date:________

PCA Needed:________________________             ADA I.D. Number:_______________________

 

 

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PART 1 – GENERAL INFORMATION

PLEASE PRINT

Last Name:____________________________________First Name:____________________________

Street Address:______________________________________________Apt #____________________

Building Complex or Name:____________________________________________________________

City:__________________________________State:___________Zip Code:_____________________

Mailing Address if different:____________________________________________________________

Telephone Number:_____________________________Date of Birth:___________________________

Social Security Number:_______________________________________________________________

If someone is assisting you in completing this application, please identify him/her:

Name:________________________________________Phone Number:_________________________

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

Name:________________________________________Phone Number:_________________________

Relationship:________________________________________________________________________

 

PART 2 – ABILITY TO USE ZTRANS FIXED-ROUTE BUSES

Please indicate below the reasons you are applying for ADA Para-transit Eligibility:

(Check all that apply)

_______I can use Ztrans fixed-route buses to go some places but in other places I cannot

               get to and from the bus stops.

_______I can use Ztrans fixed-route buses, but only if they are equipped with wheelchair

               lifts or ramps.

_______Because of my disability, I can never use Ztrans fixed-route buses.

_______Other reasons (please explain):___________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

PART 3 – INFORMATION ABOUT THE APPLICANT’S DISABILITY

 

1.         What types of disabilities prevent you from using Ztrans fixed-route buses?

            (Check all that apply)

 

            _____Physical disability                                 _____Visual impairment

            _____Developmental disability                      _____Mental disability

            _____Cognitive disability                               _____Other

 

            If other, please explain in detail:___________________________________________________

            _____________________________________________________________________________

            _____________________________________________________________________________

2.         Is the disability described above temporary or permanent?

 

            _____Temporary, I expect it to last for another _____ months.

            _____Permanent

            _____I don’t know

 

3.         Please indicate below if you use any of the following mobility aids or equipment.

           

            _____Manual wheelchair                                _____Powered wheelchair

            _____Powered scooter                                   _____Long white cane

            _____Leg braces                                             _____Walker

            _____Cane                                                      _____Crutches

            _____Service animal (describe)___________________________________________________

            _____Other (describe)___________________________________________________________

            _____I do not use any of the above aids or equipment

 

NOTE:  We may not be able to accommodate you if your wheelchair or scooter is longer than 48 inches, wider than 32 inches, or if the total weight (including the wheelchair) is more than 600 pounds.

 

4.         Do you require the assistance of a Personal Care Attendant (someone who must assist you with    daily life functions)?

 

            _____Yes, I need assistance when I travel

            _____No, I do not require assistance when I travel

 

 

 

 

3

 

 

PART 4 – QUESTIONS ABOUT USING ZTRANS FIXED-ROUTE BUSES

1.         Have you ever used Ztrans fixed-route buses?

 

            _____Yes, I typically use Ztrans fixed-route buses ______times a week

            _____Yes, I used Ztrans fixed-route buses but stopped because__________________________

            _____________________________________________________________________________

            _____No, I never use Ztrans fixed-route buses because_________________________________

            _____________________________________________________________________________

 

2.         What might help you ride Ztrans fixed-route buses? (Check all that apply)

 

            _____Route and schedule information

            _____Being able to get Ztrans fixed-route buses with wheelchair lifts or ramps

            _____A communication aid (i.e., TTY, schedules in accessible formats)

            _____Learning to use Ztrans fixed-route buses with travel training

            _____If bus stops were closer to where I live and where I need to go

            _____Other (please describe)_____________________________________________________

            _____________________________________________________________________________

            _____None of these would help

 

3.         Can you ask for and follow written or oral instructions to use Ztrans fixed-route buses?

 

            _____Yes    _____No    _____Sometimes

 

            If you selected NO or SOMETIMES, please check all that apply:

 

            _____I get confused and might get lost

            _____Other people cannot understand me

            _____I probably could with instructions

            _____Other (please describe)_____________________________________________________

            _____________________________________________________________________________

 

 

 

 

 

 

 

 

4

 

 

 

4.         Are you able to get to and from Ztrans bus stops on your own?

 

            _____Yes    _____No    _____Sometimes

 

            If you selected NO or SOMETIMES, please check all that apply:

 

            _____I cannot get places if there are no curb cuts

            _____I cannot if the streets or sidewalks are too steep

            _____I cannot cross busy streets and intersections

            _____I cannot travel outside when it is too hot

            _____I cannot find my way at night because of my limited vision

            _____I probably could with travel training

            _____I feel unsafe traveling alone

            _____Other (please describe)_____________________________________________________

            _____________________________________________________________________________

 

5.         Using a mobility aide or on your own, how far can you walk or operate your wheelchair or scooter?

 

            _____I cannot walk outside my house or apartment

            _____I can get to the curb in front of my house or apartment

            _____I can walk or use my wheelchair up to 3 blocks

            _____I can walk or use my wheelchair up to 6 blocks

            _____I can walk or use my wheelchair up to 9 blocks

 

6.         Can you wait up to 30 minutes for a Ztrans fixed-route bus at a bus stop?

 

            _____Yes

            _____Yes, if the bus stop has a bus bench or shelter

            _____No (please explain)________________________________________________________

            _____________________________________________________________________________

 

7.         Are there any other conditions that limit your ability to use Ztrans fixed-route buses?

 

            _____Yes (please describe)_______________________________________________________

            _____________________________________________________________________________

            _____No

 

 

 

5

 

 

PART 5 – CURRENT TRAVEL INFORMATION

Please list the trips you will make most frequently using ADA Complementary Para-transit Service.

 

EXAMPLE

                        FROM:                                                                                   TO:

                 35 Palm Drive                                                                    Publix, 150 Main Street         

 

                        FROM:                                                                                    TO:

(1)___________________________________                      ___________________________________

(2)___________________________________                      ___________________________________

(3)___________________________________                      ___________________________________

 

PART 6 – INFORMATION ABOUT TRAVEL TRAINING

NOTE:  Travel Training is personalized (individual or group) instruction that teaches the skills necessary to use Ztrans fixed-route bus service.

 

1.         Have you ever had any personal instruction on how to use Ztrans fixed-route bus service?

 

            _____No, I have never received any Travel Training

            _____Yes, I have received personal Travel Training instruction through an agency

                       Name of Agency:_________________________________________________________

 

            If you selected YES, please indicate below the skills you learned:

 

            _____To travel to and from bus stops

            _____To cross streets

            _____To read bus schedules and plan trips

            _____To ride the following routes:

                       Route #__________    Route #__________   Route #__________   Route #__________

            _____Other (please explain)______________________________________________________

            _____________________________________________________________________________

 

2.         Did you complete the above training?

 

            _____Yes

            _____  No

 

 

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3.         If Ztrans offers free Travel Training to anyone interested in learning how to ride the fixed-route

            bus service, would you be interested in getting information about this training?

 

            _____Yes

            _____No

 

PART 7 – APPLICANT’S CERTIFICATION

I understand the purpose of this application is to determine if there are times when I cannot use Ztrans fixed-route bus service and must therefore use the ADA Complementary Para-transit 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 certify that, to the best of my knowledge, the information in this application is true and correct.  I authorize the licensed professional who provided professional verification to release information relating to my disability to Ztrans in order to assess eligibility determinations.

 

Applicant’s Signature:________________________________________Date:___________________

 

 

 

THIS CONCLUDES THE PORTION OF THE APPLICATION TO BE COMPLETED BY APPLICANT.

 

THE LAST SECTION (PAGES 8-9) OF THIS APPLICATION MUST BE COMPLETED AND SIGNED BY A QUALIFIED AND LICENSED PROFESSIONAL.

EXAMPLES OF QUALIFIED PROFESSIONALS INCLUDE:

 

Physician (M.D. or D.O.)                                            Independent Living Specialist

Physical Therapist                                                       Rehabilitation Specialist

Occupational Therapist                                               Licensed Social Worker

Orientation and Mobility Instructor                           Optometrist

Registered Nurse                                                        Psychologist

                                                                  

 

 

 

7

 

PART 8 – PROFESSIONAL VERIFICATION

Applicant’s Name:___________________________________________________________________

 

TO BE COMPLETED BY A LICENSED PROFESSIONAL

The Americans with Disabilities Act (ADA) of 1990 requires Ztrans to provide ADA Complementary Para-transit Service to anyone who cannot use Ztrans fixed-route bus service because of a disability.  ADA Complementary Para-transit Service is provided in an area contiguous to Ztrans fixed-route bus service.  The applicant who has asked you to review and sign this application is applying to Ztrans to be considered eligible for the ADA Complementary Para-transit Service, which is intended only for those trips that the applicant cannot make on Ztrans fixed-route bus service.  This application is intended to determine when and under what circumstances the applicant can use Ztrans fixed-route bus service and when he/she requires ADA Complementary Para-transit Service.

Please review the information provided by the applicant in PARTS 2-4 of this application and then answer the questions below:

 

A.        Has the applicant been diagnosed with a physical, mental, cognitive, or other disability?

 

            _____No

            _____Yes                  Diagnosis & onset:                    ___________________________________

                                                ICD – 9 codes:                        ___________________________________

                                                DSM – IV codes:                    ___________________________________

                                                OS – visual acuity & field:     ___________________________________

                                                OD – visual acuity & field:     ___________________________________

 

B.        The applicant’s disability is:

            _____Permanent         _____Temporary – until when? _________________________________

 

C.        Please describe all conditions (physical, mental, cognitive, other) that functionally prevent the applicant from using Ztrans fixed-route buses:________________________________________

            ____________________________________________________________________________

            ___________________________________________________________________________

            ___________________________________________________________________________

 

D.        Does the applicant require the assistance of a Personal Care Attendant (PCA) when traveling on a public vehicle?

 

            _____Yes

            _____No

 

8

                                   

 

E.         To the best of your knowledge, is the information provided in PARTS 2-4 of this application true and correct?

 

            _____Yes

            _____No

            _____Do not know

 

 

Signature:___________________________________________________Date:___________________

Print or Type Name:__________________________________________________________________

Title:______________________________________________________________________________

State of New Mexico License Number:___________________________________________________

Business Address:_______________________________________Phone Number:________________

City:___________________________________________State:__________Zip Code:_____________

 

 

For more information, please call:

Ztrans

Zia Therapy Center, Inc.

900 First Street

Alamogordo, NM  88310

(575) 439-4971

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