Request for Certification of Eligibility

1. Name *

2. Street Address *

(Bldg. Complex Name / PO Box)

City * State * Zip *

Email Address:

3. Do you live inside Blacksburg Corporate Limits? This does not determine eligibility Yes  No

4. Telephone Number (Home) (Work)

5. Date of Birth

6. Gender Male  Female

7. Social Security Number (*Optional)

8. Please indicate below the reasons you are seeking ADA Paratransit Eligibility. Check all that apply:

I can use BT buses to go some places, but in other places I cannot get to or from the bus stops safely.

I can only use BT buses to go some places if they are accessible and safe.

Because of my disability, I can never use BT bus service.

9. Do you currently use the BT service at all? Yes  No

10. Have you used BT bus service by yourself in the past year? Yes  No

11. If you have used the bus service and stopped, please explain why

12. What is the closest bus stop to your home that meets your needs? Please give the location (ex: corner of Marlington and Main)

13. Can you safely get to this bus stop by yourself? Yes  No  Sometimes
If no or sometimes, why not?

14. What is it about riding a BT bus that is the most difficult for you? (ex: the bus moves before I am seated, etc.) Please list as many things as you can think of:

15. Can you ever safely cross the street by yourself? Yes  No
If yes, under what circumstances?

16. Does the weather affect your ability to safely use the BT bus service? Yes  No
If you answered yes, please explain how

17. Does your health condition or transportation disability change from day to day in a way that affects your ability to use accessible buses? Yes , good on some days, bad on others  No, doesn't change  Don't Know
If yes or don’t know is selected, explain why

18. * What disability(s) prevents you from safely using our accessible fixed route bus service? Please check all that apply:

Physical	Mental Illness
Mental / Cognitive	Visual Impairment
Other:

19. * Please list the names of ALL your disabilities/limitations. Please spell out acronyms:

20. * Is this condition temporary? Yes  No
If Yes, what is the estimated ending date? (ex: 12/2002)

21. * Do you use any of the following aids? Please check all that apply:

Manual Wheelchair	Cane
Electric Wheelchair	White Cane
Powered Scooter/Cart	Crutches
Large Electric Wheelchair	Walker
Service Animal	Leg Brace(s)/Cast
Communication Device	Oxygen Tank
Prosthesis	Other:

22. * Do you require a Personal Care Attendant (PCA) to accompany you when traveling? (If "Yes" then that person is generally required for all trips.)

Yes, when I travel I need assistance with:
Mobility	Reading
Eating	Transfers
Medication	Other:
all of the above
No

23. Can you safely get to the Paratransit vehicle without the help of another person?
Yes  No  Sometimes
If no or sometimes, please explain

24. Walk up or down three steps if there are handrails on both sides?
Always  Sometimes  Never  Not Sure

25. Use the telephone to get information?
Always  Sometimes  Never  Not Sure

26. Travel 200 feet on a level sidewalk when the weather is good?
Always  Sometimes  Never  Not Sure

27. If you are able to travel 200 feet, how long does it take you?
< 5 min  5-10 min  10+ min  Not Sure

28. Use a ramp on a low floor accessible bus?
Always  Sometimes  Never  Not Sure

29. Travel ¼ mile on a level sidewalk, if the weather is good?
Always  Sometimes  Never  Not Sure

30. If you are able to travel ¼ mile, how long does it take you?
< 5 min  5-10 min  10+ min  Not Sure

31. Wait 15 minutes in good weather outdoors without a place to sit?
Always  Sometimes  Never  Not Sure

32. Wait 30 minutes or more in good weather outdoors without a place to sit?
Always  Sometimes  Never  Not Sure

33. Step on and off the curb from the sidewalk?
Always  Sometimes  Never  Not Sure

34. Travel up or down a gradual hill on the sidewalk, if the weather is good?
Always  Sometimes  Never  Not Sure

35. Find your own way to the bus stop safely, if someone shows you the way once?
Always  Sometimes  Never  Not Sure

36. Currently travel by yourself safely?
Always  Sometimes  Never  Not Sure

37. If the weather is good and there are no barriers in the way, what is the farthest you can walk or travel outdoors on a level sidewalk without stopping to rest?
I can’t travel outdoors alone at all
Curb in front of my house
200 feet
¼ mile
½ mile
¾ mile
More than ¾ mile
Not Sure
Other:

38. Name of eye disease/condition

39. My vision is worse during these conditions:
Bright sunlight
Dimly lit or shaded places
Night time
Glare (from snow or vehicles)
See the same in different lighting conditions
I have no vision at all

40. My eye condition is considered to be
Stable
Degenerative
Other:

41. Most often, I use the following mobility aids when I walk outdoors:
Sighted (person) guide
Dog guide
Long white cane
Optical devices (telescope, light, special glasses, etc.)
None of the above
Other:

42. I have difficulty safely navigating through traffic conditions due to:
Insufficient peripheral vision
Inability to judge distances and speeds of oncoming vehicles
Difficulty seeing motorcycles and bicycles
Difficulty seeing traffic lights
Other:

43. I can easily see steps and curbs Yes  No  Sometimes

44. While waiting to board my bus, I can see bus routes on the buses Yes  No  Sometimes

45. I can safely find my destination without assistance Yes  No  Sometimes

46. Do you have multiple steps at the entrance you use at your residence? Yes  No

47. How would you describe the terrain where you live? (ex: steep hill, flat, long gradual hill, etc.)

48. Are there sidewalks in your neighborhood? Yes  No

49. Please use this space to tell us anything else you would like us to know about your travel challenges and your ability to use BT bus service

50. Please list the trips you may take most often, which you believe you would not be able to use the accessible fixed route bus. Factors should include being able to get to the bus stop, wait, board and ride or disembark from the bus as well as get from the stop to your destination. This information will not be used to schedule any trips. You must call the office for all trip requests. Destination Addresses:

Name: *

Relationship:

Telephone Number (Day) * (Evening) *

Address *

City * State * Zip *

Name:

Telephone Number (Home) (Work)

Address

City State Zip