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LAWRENCETRANSITSYSTEM1260TIMBEREDGERDLAWRENCE,KS66049PHONE7853127054FAX7853127958WWWLAWRENCETRANSITORGTLIFTPARATRANSITELIGIBILITYAPPLICATIONPARTBPROFESSIONALVERIFICATIONDEARQUALIFIEDPROFESSIONALTHEAPPLICATIONFORMBELOWCONTAINSQUESTIONSTOASSISTYOUINEVALUATINGTHEAPPLICANTTODETERMINETHEIRABILITYORINABILITYTORIDELAWRENCETRANSITSYSTEMREGULARFIXEDROUTETSERVICEUNASSISTEDTHEAPPLICANTISCURRENTLYAPPLYINGFORTLIFTADACOMPLEMENTARYPARATRANSITSERVICETLIFTSERVICEISSTRICTLYLIMITEDFORONLYTHOSEPERSONSWITHDISABILITIESREQUIRINGPUBLICTRANSPORTATIONSERVICESINTHECITYOFLAWRENCEWHOAREUNABLETOUTILIZEREGULARFIXEDROUTETBUSSERVICETLIFTISADOORTODOORDEMANDRESPONSESERVICEWHERECUSTOMERSCALLAHEADTOSCHEDULETRIPSANDMUSTBEABLETOMEETTHEVEHICLEATSTREETLEVELFORPICKUPPLEASEREADTHEFOLLOWINGADAAMERICANSWITHDISABILITIESACTDEFINITIONOFAPERSONWITHADISABILITY,ASITRELATESTOPUBLICTRANSITANYPERSONWITHADISABILITYWHOISUNABLE,ASARESULTOFAPHYSICALORMENTALIMPAIRMENT,TOBOARD,RIDEORDISEMBARKFROMANACCESSIBLEVEHICLEWHEELCHAIRLIFTEQUIPPEDINDEPENDENTLYORCOMPLETETRANSFERSWITHOUTTHEASSISTANCEOFANOTHERINDIVIDUALAND/ORANYPERSONWITHADISABILITYWHOHASASPECIFICIMPAIRMENTRELATEDCONDITIONTHATPREVENTSTHEMFROMTRAVELINGTOANDFROMABUSSTOPONTHEPUBLICBUSSYSTEMARCHITECTURALANDENVIRONMENTALBARRIERSSUCHASDISTANCE,TERRAINORWEATHERDONOT,STANDINGALONE,FORMABASISFORELIGIBILITYHOWEVER,CONSIDERATIONSHOULDBEGIVENTOTHEINTERACTIONOFENVIRONMENTALCONDITIONSTERRAINANDWEATHERWITHTHEINDIVIDUALSIMPAIRMENTRELATEDCONDITION_NAMEOFAPPLICANTPOBOX/STREETADDRESSCITYSTATEZIPCODEISTHEAPPLICANTUNABLETOUSETFIXEDROUTESERVICEASOUTLINEDABOVEYES_NO_IFNO,STOPHEREANDDONTCOMPLETETHERESTOFTHEAPPLICATIONFORMPLEASESIGN,DATEANDMAILTHISPAGETOLAWRENCETRANSITSYSTEM,1260TIMBEREDGERD,LAWRENCE,KS66049_PROFESSIONALSIGNATUREDATEPRINTEDNAMECERTIFICATION/LICENSUREPHONENUMBERIFYOUANSWEREDYESTOTHEABOVEQUESTION,PLEASECONTINUETOTHENEXTPAGEANDANSWERALLOFTHEQUESTIONSQUESTIONSREGARDINGTHISFORMMAYBEDIRECTEDTOLAWRENCETRANSITSYSTEMAT7853127054WHILEANSWERINGTHEFOLLOWINGQUESTIONS,KEEPINMINDTHISINFORMATIONWILLBEONEELEMENTINTHEELIGIBILITYDETERMINATIONMADEBYTHETRANSITSYSTEMSSTAFF/CONTRACTORPLEASEVERIFYTHEDISABILITYCLAIMEDBYTHEAPPLICANT,THEEXTENTOFTHISDISABILITY,ANDFORFUNCTIONALASSESSMENTSASTOTHEAPPLICANTSABILITYTOPERFORMACTIVITIESRELATEDTOUSINGAFIXEDROUTETRANSITSERVICEYOURINPUTWILLBEPARTICULARLYIMPORTANTWHEREAPPLICANTSHAVECLAIMEDA“HIDDEN”O(jiān)R“NONVISIBLE”DISABILITYEGAMEDICALCONDITIONSUCHASACARDIACORPULMONARYCONDITION,MENTALILLNESS,ORAJOINTDISEASEETCTHISVERIFICATIONWILLALSOASSISTINDETERMININGTHEDEGREEOFCOGNITIVECAPABILITY1HAVEYOUEVEREXAMINED/EVALUATEDTHEAPPLICANTINTHEPASTYES_NO_IFYES,WASEXAMINATION/EVALUATIONWITHINTHELASTTWELVEMONTHSYES_NO_LENGTHOFTIMEINTREATMENT/UNDERYOURCARE_2WHATISTHEAPPLICANTSSPECIFICDISABILITYORHEALTHCONDITION/LIMITATIONANDHOWDOESITLIMITORPREVENTHIS/HERABILITYTOTRAVELINDEPENDENTLYORUTILIZEREGULARFIXEDROUTETSERVICE_CERTIFIEDLEGALLYBLIND_LOSSORINABILITYTOUSEONEORMORELIMBS_SEVEREEFFECTSOFSTROKE_PARALYSISAFFECTINGMOBILITY,SPEECH,VISIONORMEMORY_SEVEREARTHRITIS_AUTOIMMUNEDISORDERS,FOREXAMPLE,LUPUSORSCLERODERMAETC_SEVERECARDIACAND/ORRESPIRATORYIMPAIRMENTAFFECTINGSTRENGTHAND/ORENDURANCE_SEVEREEMOTIONALDISORDERMAYREQUIREANESCORT_DEVELOPMENTALDISABILITIES,FOREXAMPLE,MENTALRETARDATION,CEREBRALPALSY,EPILEPSY,AUTISMORNEUROLOGICALDISORDER,ETC_HEARINGLOSSACCOMPANIEDBYANINABILITYTOUNDERSTANDSPEECHWITH/WITHOUTAHEARINGAID_OTHERPLEASEEXPLAINTHEMEDICALDIAGNOSISANDTHENDESCRIBETHEDISABILITYORHEALTHCONDITION/LIMITATIONUSEOTHERSIDEOFPAGEIFNECESSARY_DATEOFONSET_3ISTHEAPPLICANTSDISABILITYPERMANENTYES_NO_IFTEMPORARY,HOWLONG_ISTHISAPPLICANTSDISABILITYSEASONAL_IFSO,WHICHSEASONS_4WHATMOBILITYAIDSDOESTHEAPPLICANTUTILIZECHECKALLTHATAPPLYMANUALWHEELCHAIR_ELECTRICWHEELCHAIR_POWEREDSCOOTER_CANE_WALKER_WHITECANE_SERVICEANIMAL_CRUTCHES_OXYGEN_OTHERPLEASELIST_5DOESTHEAPPLICANTREQUIREAPERSONALCAREATTENDANTPCAWHENTRAVELINGONTRANSITVEHICLESRIDERSMUSTPROVIDETHEIROWNPCANEVER_SOMETIMES_ALWAYS_IFAPCAISNEEDED,EXPLAINWHY_6WHICHOFTHEFOLLOWINGWEATHERCONDITIONSIMPACTTHEAPPLICANTSDISABILITYORHEALTHCONDITIONSUCHTHATITPREVENTSHIM/HERFROMINDEPENDENTLYGETTINGTOAND/ORFROMABUSSTOPINDICATEHEAT_COLD_HUMIDITY_SNOW_ICE_POLLUTION/ALLERGIES_OTHER_N/A_WHATSPECIFICWEATHERCONDITIONPREVENTSTHISPERSONFROMGETTINGAROUNDONHIS/HEROWNHOWSO_7DOESROUGHTERRAINMAKEITHARDFORTHEAPPLICANTTOTRAVELYES_NO_SOMETIMES_IFYOUANSWEREDYESORSOMETIMES,DESCRIBEYOURDEFINITIONOFROUGHTERRAINANDHOWTHATMAKESITDIFFICULTFORTHEAPPLICANTTOTRAVEL_8ISAPPLICANTABLETOCHECKALLTHATAPPLY_UNDERSTANDAND/ORPROCESSINFORMATION_ASKFORORFOLLOWWRITTENORORALINFORMATION,SUCHASSCHEDULESINCLUDINGTDD,AUDIOTAPEORVOICE_FIGUREOUTTHECORRECTFARE_FOLLOWINSTRUCTIONSINANEMERGENCY_RECOGNIZEHIS/HERDESTINATIONWHILEONTHEBUS_ONCEHE/SHEGETSOFFTHEBUS,LOCATEANDREACHHIS/HERDESTINATION_CROSSABUSYINTERSECTION_FINDHIS/HERWAYBETWEENFAMILIARLOCATIONS_SIGNALTHEBUSDRIVERTOGETOFFTHEBUSATFAMILIARSTOPANDTHENGETOFFTHEBUSASSUMETHEDRIVERTHECALLSALLSTOPS_GRASPCOINS,PASSES,ANDHANDLES_COMMUNICATEADDRESSES,DESTINATIONS,ANDTELEPHONENUMBERSONREQUEST_DEALWITHUNEXPECTEDSITUATIONSORUNEXPECTEDCHANGESINROUTINE,EG,ROUTECHANGEDDUETOROADCONSTRUCTION,REGULARBUSSTOPCLOSED_GOUPANDDOWNSTEPSYOURNAMEANDTITLE_CERTIFICATE/LICENSURE_OFFICEADDRESS_OFFICETELEPHONENUMBER_SIGNATURE_DATE_QUALIFIEDPROFESSIONALPLEASEFORWARDTHESIGNEDORIGINALTOLAWRENCETRANSITSYSTEMAT1260TIMBEREDGERD,LAWRENCE,KS66049YOUMAYALSOFAXACOPYTO7853127958TOEXPEDITETHEPROCESS,BUTTHESIGNEDORIGINALMUSTBEFORWARDEDTOTHELAWRENCETRANSITSYSTEM,ATTNTLIFTCERTIFICATIONOFFICERTHANKYOUFORYOURCOOPERATIONAUTHORIZATIONFORMFORDISCLOSUREOFPROTECTEDHEATHINFORMATIONI_AUTHORIZETHEQUALIFIEDPROFESSIONALPRINTEDNAMEOFPATIENT_COMPLETINGPARTBQUALIFIEDPROFESSIONALPRINTEDNAMEANDTITLEOFQUALIFIEDPROFESSIONALVERIFICATIONOFTHETLIFTPARATRANSITELIGIBILITYAPPLICATIONONMYBEHALF,TORELEASETHISINFORMATIONABOUTMYDISABILITYANDABILITIESTOUSETHEACCESSIBLEREGULARTFIXEDROUTEBUSSERVICETOREPRESENTATIVESOFTHELAWRENCETRANSITSYSTEMFORTHEIRREVIEWASWELLASANYSUPPORTINGOROTHERPERTINENTINFORMATIONABOUTMYHEALTHORMEDICALCONDITIONTOASSISTTHELAWRENCETRANSITSYSTEMSOLELYFORTHEPURPOSEOFDETERMININGELIGIBILITYFORTLIFTADACOMPLEMENTARYPARATRANSITSERVICEINTHECITYOFLAWRENCE,KANSASIUNDERSTANDTHATALLMEDICALINFORMATIONABOUTMYDISABILITYWILLBEKEPTSTRICTLYCONFIDENTIALIUNDERSTANDTHATIDONOTHAVETOSIGNTHISAUTHORIZATIONINORDERTOBECONSIDEREDFORSERVICES,BUTIUNDERSTANDTHATNOWEIGHTWILLBEGIVENTOMEDICALCONDITIONSCLAIMEDWHICHCANNOTBEVERIFIEDINFACT,IHAVETHERIGHTTOREFUSETOSIGNTHISAUTHORIZATIONWHENMYINFORMATIONISUSEDORDISCLOSEDPURSUANTTOTHISAUTHORIZATION,ITMAYBESUBJECTTOREDISCLOSUREBYTHERECIPIENTANDMAYNOLONGERBEPROTECTEDBYTHEFEDERALHIPAAPRIVACYRULEIHAVETHERIGHTTOREVOKETHISAUTHORIZATIONINWRITINGEXCEPTTOTHEEXTENTTHATTHELAWRENCETRANSITSYSTEMHASACTEDINRELIANCEUPONTHISAUTHORIZATIONMYWRITTENREVOCATIONMUSTBESUBMITTEDTOTHETLIFTCERTIFICATIONO

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