HomeMy WebLinkAboutADA_ApplicationGO PLUS ADA Application, revised 03/2019
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Application Form for ADA Paratransit Services
Introduction:
The Americans with Disabilities Act (ADA) of 1990 requires GO Transit to provide paratransit
service (called “GO Plus") to persons with disabilities who cannot access the fixed-route bus
system due to their disability. Please complete this application if you have a disability that
prevents you from using the city bus system. Applicants must reside in the City of Oshkosh to
qualify.
Application Instructions:
The applicant or applicant’s legal guardian needs to ensure all sections of the form are
completed. This includes the following sections: Applicant Information, About Your
Disability, About Your Mobility, Release of Information, and Request for Professional
Verification. If necessary, use the back side of each page to continue answers. The Request for
Professional Verification section will need to be completed by a licensed professional familiar
with the applicant’s disability. Please keep the entire application intact for the professional
verification. Incomplete applications will not be processed and will be returned to the applicant.
If you have any questions about the application, please call GO Plus at 232-5340.
Application Review Process:
In addition to the initial application review, it may be necessary for GO Plus to contact
professionals listed in the application; conduct an in-person assessment; and/or schedule an
appointment with occupational health to determine if the applicant is eligible. An eligibility
determination will be made within 21 days of receipt of a completed application. The review
process is suspended if there is no response to requests for additional information from the
applicant or professionals/contacts listed by the applicant.
Applicants that qualify for the service will be mailed an ID card, service policies, and instructions
on how to use the program. If the application is denied, the decision can be appealed. A
description of the appeals process will be included with the denial letter to the applicant.
The application process is an ADA requirement and designed to strictly limit eligibility according
to the regulatory criteria defined in the ADA. Individuals that are able use the city bus for all trips
during city bus hours are not eligible for ADA paratransit service. This ensures the best possible
service for individuals that do qualify for and rely on paratransit. Existing paratransit users that
must reapply for paratransit service are not guaranteed continued eligibility based on a previous
certification.
Additional Paratransit Programs:
GO Plus also offers additional non-ADA paratransit programs tailored to help seniors, low-
income workers, and rural Winnebago County residents. For more information about other GO
Plus paratransit programs, please call 232-5340 or visit www.rideGOtransit.com .
Please return completed application to:
Mail: GO Transit, 926 Dempsey Trail, Oshkosh, WI 54902;
Fax: (920) 232-5343; or
Email: transit@oshkoshwi.gov
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REQUIRED INFORMATION FOR CERTIFICATION OF ADA ELIGIBILITY
Please type or print clearly. Incomplete applications will be returned.
Last name First name M.I.
Current address Apt. #:
Name of residence facility (if applicable)
City State Zip
Date of birth / / Gender: Female Male
Telephone numbers (home) (cell)
1. Are you eligible for rides under Title 19 (XIX), also known as MA rides provided under
Medicaid (rides to/from medical appointments)? Not to be confused with Medicare.
Yes No
2. If you are a member/participant of the following programs, please check one.
Lakeland Care District (Family Care) IRIS Neither
1. What is your disability or medical condition that prevents you from using the city bus?
2. Explain how your disability prevents you from independently using the city bus. Be
specific:
3. Is the condition you describe temporary? Yes No
If “Yes,” the expected duration is until: / /
4. Is your condition affected by weather, temperature, and/or environmental conditions?
Yes No
If “Yes,” please explain.
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Did you know that all city buses are accessible? All GO Transit buses have wheelchair
ramps and kneelers (lowers bus near curb level) for ease in boarding. Bus drivers also make
key location announcements.
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5. Are there any other effects of your disability or health condition of which we should be
aware?
1. Do you use any of the following mobility aids or specialized equipment while
traveling? Check all that apply.
Cane Service Animal Communication Board
White Cane Power Wheelchair Oxygen Tank
Walker Power Scooter (3-Wheeler) Other Aid
Crutches Manual Wheelchair
Augmentative Communication Device
I do not require any assistive devices
2. If you use a wheelchair or scooter while traveling, what are the specifications?
Wheelchair/scooter Make Model
How wide is it*? inches How long is it*? inches
*measured 2 inches above the ground
How heavy is it when occupied (total weight of chair and person)? pounds
3. How far can you travel independently without assistance of another person? If you
use a mobility aid, please include use of the aid in your response.
Less than 100 feet Only 1 block ¼ mile (3 blocks)
½ mile (6 blocks) ¾ mile (9 blocks) more than ¾ mile (>9 blocks)
4. How far from your home is the nearest city bus stop?
Less than 1 block 1-2 blocks 3-4 blocks
5 or more blocks I don’t know
5. Can you wait outside without support for 10 minutes?
Yes No Sometimes
If “Sometimes,” explain:
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The ADA defines a “common wheelchair” as no more than 30 inches wide, 48 inches long,
and 600 pounds when occupied. If your mobility device exceeds these dimensions, the ADA
does not guarantee paratransit service.
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6. Have you ever ridden the city bus in Oshkosh on your own? Yes No
If “Yes,” list the trips when you are able to use the city bus.
If “No,” describe why you have not used the city bus for any trips.
7. If personalized travel training was provided to teach you how to ride the city bus,
would you be willing to participate? Yes No
1. So GO Plus can verify the information you provided, please list the name(s) of at
least one professional, which may include a physician, agency representative or other
professional familiar with your disability.
Professional’s name Title
Facility Telephone #
Address
City State Zip
Professional’s name Title
Facility Telephone #
Address
City State Zip
I, the applicant, understand that the purpose of this application form is to determine my eligibility
to use GO Plus paratransit services. I hereby authorize the above professional(s) to provide the
required information to GO Plus. I certify that all of the information here and on the preceding
pages is complete and true. I agree to release the information requested to GO Plus and any
eligibility review panel. I understand that the information contained herein will be treated as
confidential and will not be shared with any other person or company unless authorized or
legally required. I understand further that GO Plus reserves the right to request additional
information at its discretion.
Signature of applicant Date / /
Printed name of applicant Date / /
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Printed name of preparer (if applicable)
If preparer represents an agency, please print the agency info here:
Agency name Phone #
Signature of parent or legal guardian Date / /
If you are able to ride the city bus for some or all trips, but need training, feel free to contact
GO Transit at (920) 232-5340 or email transit@oshkoshwi.gov. We can provide travel
training assistance to anyone that is able to use the bus.
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REQUEST FOR PROFESSIONAL VERIFICATION
Please keep the entire application attached to this form.
All information requested below must be completed by a licensed professional.
The individual who has asked you to review this application and complete the form below is
applying to GO Plus to be considered eligible for Americans with Disabilities Act (ADA)
paratransit service. ADA paratransit service is intended ONLY for those trips that the person
cannot take on the regular public bus system due to his/her disability.
Eligibility is strictly limited to individuals with disabilities that meet regulatory criteria defined in
the ADA. The information requested in this application will allow GO Plus to make an
appropriate determination of the applicant’s eligibility for this service. It is important to fully
complete this form to avoid delay in the evaluation process. Thank you for your cooperation in
this matter.
The information obtained will be treated confidentially and only be used to determine eligibility.
1. Applicant’s name Date of birth / /
2. Medical diagnosis of disability or heath condition:
3. Is the disability temporary? Yes No
If “Yes,” the expected duration is until: / /
4. Please review the applicant’s responses to his/her completed application. To the best
of your knowledge, is the information about the applicant’s disability and mobility
accurate? Yes No
5. Are there any other effects of the applicant’s disability or health condition of which we
should be aware?
Name of professional Title
Facility Office telephone #
Address
City State Zip
By signing this form, I verify that the information provided is true and correct.
Signature Date / /
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