1 PARATRANSIT ELIGIBILITY APPLICATION The Indianapolis Public Transportation Corporation (IndyGo) provides paratransit services in specially equipped vans to persons who cannot utilize the regular bus system. To be eligible for this service, individuals must have disabilities that prevent use of the regular fixed-route bus system. Eligible individuals served do not have to reside in the area, but they must be traveling within the Open Door service area. All applicants, whether new or applying for re-certification, must submit a new application and professional verification form as well as complete an in-person assessment before your information can be processed. The ADA certification process may include a functional assessment to determine if and under what conditions you can use regular bus services. The assessment focuses on your abilities and will be performed at no cost to you. After completing this application and the professional verification form (completed by a physician or qualified certifying agent), please call 614-9260 to schedule your functional assessment and bring your forms with you to the assessment. If you have questions about the assessment process, please do not hesitate to call 614-9260 or email assessments@indygo.net. General Questions: (please print) Check one: New Application Renewal Last Name: ________________________ First Name: _________________ ______ Middle Initial: _____ Birth Date: _______ ____ Gender: Male ___ Female ___ Address: _______________________________________________________________ Apt. __________ City: ____________________________________________________ State: ________ Zip: __________ Phone Numbers: Home ____________________ Cell __________________ Work__________________ In case of emergency, contact: Name: _________________________________ Relationship ____________________ Day Phone: ___________________________ Evening Phone: ____________________ Voluntary Questions: (This data is used for analysis only and will not impact eligibility for program access.) Ethnicity: __________ _____ Do you receive Medicaid? (Hoosier Healthwise) Yes___ No___ For Office Use Only. 1501Eligible? W. Washington Street Indianapolis, YES ____ No ____IN 46222 phone (317) 614-9260 fax (317) 614-9316 Application revised 6/2014 LSO PCA? YES____ NO_____ ID #_____________ Date: ______ Approved/Declined by: ________________________________ 2 APPLICANT’S CERTIFICATION Applicant’s Certification: I understand that the purpose of this form is to determine if there are times that I cannot use regular city bus services and therefore need the shared ride services of Open Door. I certify that the information provided in this application is accurate and I understand that I must complete a functional assessment of my abilities. My signature below also gives the Open Door Assessment Center permission to use data gained from this assessment in research studies that will maintain my anonymity. Signature: ____________________________________ Date: ________________ Person completing form for Applicant: ___________________________________ Relationship: __________________________________ Date: ________________ INFORMATION ABOUT YOUR CONDITION OR DISABILITY & MOBILITY AIDS Which of the following mobility aids do you use? Please check all that apply. _____Walking Cane _____Manual wheelchair _____White cane _____Powered wheelchair _____Walker _____Prosthesis _____None _____Powered scooter/cart _____Leg braces _____Portable oxygen _____Service animal _____Crutches _____Communication board _____Other (please describe) ___________________________ How long have you used your current aids? __________________________________ If you use a wheelchair or scooter, is it: 30 Inches Wide or Less Yes ____ No ____ 48 Inches Long or Less Yes ____ No ____ 600 Pounds or Less when Occupied? Yes ____ No ____ Please describe your health condition/disability and how it prevents you from using the Fixed Route buses: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________ 1501 W. Washington Street Indianapolis, IN 46222 phone (317) 614-9260 fax (317) 614-9316 Application revised 6/2014 LSO 3 Is this condition/disability temporary? Yes ____ No ____ If yes, what is the expected duration of this condition or disability? ______________ Does your condition/disability change from day-to-day in ways that affect your ability to use Fixed Route service? Yes ____ No ____ (Please explain :) ___________________________________________________________________________________ ___________________________________________________________________________________ __________________ Please read the following statements and check all of those that best describe what you believe are your ability to use regular fixed route bus services by yourself. _____ I use fixed route buses frequently. _____ I can use the bus sometimes, in the right conditions _____ I have difficulty understanding and remembering all of the things that I would have to do to use Fixed Route buses. _____ I believe that I could learn to ride the bus, if someone taught me. _____ I can get to and from the bus stop if the distance is not too great and the route is free of barriers. _____ I can never use the bus by myself. Do you need to travel with someone who assists you? Always ___ Sometimes ___ Never____ If you travel with someone who assists you, please describe how this person helps you: ___________________________________________________________________________________ ___________________________________________________________________________________ __________________ YOUR FUNCTIONAL ABILITIES Your answers to questions in this section will help us better understand your functional abilities in specific areas. Your answers should be based on how you feel most of the time, under normal circumstances, using your mobility aids, and whether you perform these activities independently or need assistance. Please describe any problems you have getting to and from bus stops: ___________________________________________________________________________________ ___________________________________________________________________________________ __________________ 1501 W. Washington Street Indianapolis, IN 46222 phone (317) 614-9260 fax (317) 614-9316 Application revised 6/2014 LSO 4 __________________________________________________________________________________ __________ Please describe any problems you have getting on, riding, and getting off the Fixed Route buses: ___________________________________________________________________________________ ___________________________________________________________________________________ __________________ ___________________________________________________________________________________ _________ Please describe any problems you have understanding and remembering how to use the Fixed Route buses: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________ YOUR CURRENT TRAVEL Please list your five most frequent destinations. Place or Address How do you get there now? How often do you go there in a month? 1. 2. 3. 4. 5. Please use this space to tell us anything else you would like us to know about your travel challenges and your ability to use Fixed Route buses or Open Door. ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ____________________________________ 1501 W. Washington Street Indianapolis, IN 46222 phone (317) 614-9260 fax (317) 614-9316 Application revised 6/2014 LSO 5 Thank you for your time and input. 1501 W. Washington Street Indianapolis, IN 46222 phone (317) 614-9260 fax (317) 614-9316 Application revised 6/2014 LSO