4.
I can cross the street if there are curb cuts.
Always
Sometimes
Never
5. I can travel up/down a gradual hill
in good weather conditions.
Always
Sometimes
Never
6. I can find my way to the Fixed Route Public Transit Service (CTTransit) stop if someone shows me once.
Always
Sometimes
Never
7. I am able to wait for 10 minutes
at a Fixed Route Public Transit Service (CTTransit) stop that does not have seats
and a shelter.
Always
Sometimes
Never
8. I am able to ask
for, understand, and follow directions.
Always
Sometimes
Never
9.
I am able to detect curbs, ramps, and other drop off
areas.
Always
Sometimes
Never
Answer
the following questions by checking all that apply.
10.
What barriers in your surroundings would make it difficult for
you to use the Fixed Route Public Transit Service (CTTransit)?
Lack of curb cuts
No Sidewalks
Steep hill
Sidewalks are in poor condition
Busy streets I must cross
No crosswalks at street corners
Other
11.
Can you get on and off a Fixed Route Public Transit Service (CTTransit)?
Yes, I can climb steps
I probably could with instruction
Yes, I can use the lift and/or ramp
No (Please explain)
12.
Is there any medication that affects your daily travel?
TRAVEL
TRAINING INFORMATION
I
could use the Fixed Route Public Transit Services (CTTransit) if I had general
knowledge
about routes and times.
Yes
No
Sometimes
Travel
Training is a free service, which assists people with disabilities
to
learn how to ride and use the Fixed Route Public Transit Service (CTTransit) service.
Would
you like more information?
Yes
No
INFORMATION
ABOUT YOUR DISABILITY
13.
What type of disability prevents you from using the
Fixed Route Public Transit Service (CTTransit) system? Check all that apply:
Physical
Visual
Cognitive
Mental Health
Hearing
None
Other
Identify Disability by Name(s)
Please
describe your disability in detail.
14.
Is this condition temporary?
Yes
No
If yes, expected duration?
15.
Do you require the assistance of a personal care attendant?
No, I do not require an attendant
Yes, I do require an attendant
Sometimes, because of my disability there are times
when I need assistance
16. Do you use any of the following devices? Check all
that apply:
*Manual Wheelchair
* Power Scooter
*Electric Wheelchair
Cane
Walker
White Cane
Braces
Oxygen Tank
Crutches
Communication Board
Service Animal
None
Cart
Other
* Section 37.3 of the DOT regulations implementing the Americans with Disabilities Act of 1990 (ADA) (49 CFR Parts 27, 37, and 38) defines a "wheelchair" as a mobility aid belonging to any class of three or more wheeled devices ... whether operated manually or powered. Scooters meeting the definition of "wheelchair" are included. ADA operators must carry any wheelchair and occupant regardless of size and weight if the lift and the vehicle can physically accommodate them, unless doing so is inconsistent with legitimate safety requirements. ADA operators are also not required to permit wheelchairs to ride in places other than designated securement locations in the vehicle.
|