PART TWO:  C-Tran Specialized Door-to-Door Services

Application & Authorization to Release Information Regarding Eligibility for C-Tran

 

I hereby authorize the professional listed in Section Two below to provide information to C-Tran regarding my ability to use C-Tran fixed route bus service.  I understand that all information will be kept confidential and be used only for transit-related purposes.

 

Section One:

Applicant's signature ___________________________ Date _____________

Print Name ______________________________________________________

Street address ___________________________________________________

Mailing address ________________E-mail address_____________________

City _____________________________ Zip code _______________________

Telephone: Home _____________________ Work ______________________

Accessible format materials required?   Braille      Large print    Audio cassette

 

The professional identified below must be one of the following currently licensed professionals: registered nurse, physician, clinical social worker, psychologist, physical therapist, occupational therapist, speech pathologist, vocational rehabilitation specialist, or recreation therapist.

 

Section Two:

Name of professional _____________________________________________

Clinic or agency __________________________________________________

Street address ___________________________________________________

City ____________________________________ Zip ____________________

Telephone _______________________________

Page 1:  To be completed by Applicant or Legal Guardian ONLY. Please print clearly.

 

If this application has been completed by someone other than the applicant:

Signature ________________________________  Date ___________________

Print name _______________________________________________________

Street address ____________________________________________________

City ____________________________________  Zip _____________________

Telephone: Home ____________________ Work ________________________

Relationship to applicant ____________________________________________

Return completed form to:

Town of Cary Planning Dept., Attn: A. Tenorio, Cary Transit, PO Box 8005,

Cary, NC 27512

Or fax to (919) 380-6426

 

Date mailed:_________________

 

Professional Verification Questionnaire

Regarding Eligibility for C-Tran

 

This questionnaire must be completed by one of the following currently licensed professionals: registered nurse, physician, psychiatrist, clinical social worker, psychologist, physical therapist, occupational therapist, speech pathologist, vocational rehabilitation specialist, or recreation therapist.

The Americans with Disabilities Act of 1990 (ADA) is a civil rights bill which bans discrimination against people with disabilities.  To meet their needs, C-Tran provides both fixed route bus service (buses which operate over fixed streets on fixed schedules with lifts) and C-Tran door-to-door service (vans which go door to door upon request).  C-Tran has limited resources with which to provide service to the community, so making an accurate determination of eligibility is crucial.

 

Name of applicant (print):________________________________ has applied for certification to use C-Tran’s Door-to-door service, and has given you the authority to provide information that will allow C-Tran to make an accurate determination of the need for C-Tran door-to-door service.  Please answer all questions as accurately as possible so those individuals who are truly in need of this special transit service will have access to it.  All information will be kept confidential and be used only for transit-related purposes.

 

If you have questions about how to complete this form, call 481-2020.  Your quick response is greatly appreciated by C-Tran and by the applicant. Thank you.

 

1.   Which of these mobility aids or equipment does the applicant use to get around?

      (check all that apply)

 

   None                        Manual wheelchair                                     Service animal

   Cane                        Powered wheelchair                            Picture board

   Crutches                  Powered scooter/cart                                Alphabet board

   Walker                     Leg braces         

   White cane              Portable oxygen 

   Other _____________________________________________________

 

2.   Does applicant normally travel with a personal care attendant (PCA)?  A personal care attendant is someone designated or employed specifically to assist the applicant with the completion of at least one daily activity on a regular basis, such as mobility assistance, personal care, eating, or communication.

   Always

   Sometimes--Please explain __________________________________________________

   No

 

3.   Could the applicant pay the fare without assistance?  C-Tran buses are equipped with fare boxes immediately inside the front door of the bus, next to the driver. Fares may be paid with coins, punch tickets, and passes.

   Yes

   Yes, if someone could purchase tickets or passes for the applicant

   Yes, with training

   No--Please explain _________________________________________________________

 

~turn over to complete questionnaire~

Page 2

 

4.   Could the applicant ride on a C-Tran bus for 20 to 25 minutes?  The typical ride time on a C-Tran bus is 20 to 25 minutes. The buses are equipped with forward and side facing seats. There are passenger assists located along the top of each seat, overhead at 70" above the floor along both sides of the aisle, and vertically from ceiling to floor at several locations.

   Yes

   Yes, except under these circumstances--Please explain ____________________________

      ________________________________________________________________________

   No--Please explain _________________________________________________________

 

5. Could the applicant communicate with the bus driver and/or other passengers?  It is sometimes necessary during the course of a bus trip to communicate with the bus driver and/or other passengers.

   Yes

   No--Please explain _________________________________________________________

      ________________________________________________________________________

 

6. What is the applicant's physical or cognitive disability?

 _______________________________________________________________________

 

7. Is this disability temporary?

   Yes--How long do you expect it to last? _____ months

   No

   I don't know--Please explain _________________________________________________

 

8. Does this disability change from time to time in ways which affect the applicant's ability to get around?

   Yes--Please explain ________________________________________________________

   No

 

9. Signature of Medical Provider____________________________Date________________

Printed name _______________________________________________________________

Clinic or agency name _______________________________________________________

Street address ______________________________________________________________

City _______________________________________________ Zip ____________________

Telephone __________________________________________________________________

License, certification, or registration number ____________________________________

Capacity in which you know the applicant _______________________________________

 

Return completed forms to:

Town of Cary Planning Dept., A. Tenorio, Cary Transit, PO Box 8005, Cary, NC 27512

Or fax to (919) 380-6426

 

C-Tran is a service operated by First Transit, Inc. and provided by the Town of Cary,

PO Box 8005, Cary, NC 27512.  Contact:  Ana V. Tenorio, Cary Transit, Town of Cary Planning Department, Phone: (919) 469-4086, Fax (919) 380-6426, Email: ana.tenorio@townofcary.org, and/or www.townofcary.org for more information.

 

 

                                                                                                                             Revised 10/25/07