Fares Plan A Trip Services Travel Information

Application for ADA - Paratransit Eligibility

To report an emergency, call 911 (where applicable) or your local law enforcement office. This form is for non-emergency contact only. We will contact you once we have received your submission, if your contact information is provided. If you do not hear from us in 48 hours, please call our office

Pine Bluff Transit provides, to qualifying individuals, Paratransit bus service meeting the requirements of the Americans with Disabilities Act. This service allows for curb to curb pickup during the normal hours of bus service (6:00 am to 6:00 pm Monday through Friday) and requires you to schedule a ride by 4:00 pm the day before your requested trip.

A pick-up time may be scheduled 1 hour ahead of the requested time and/or 1 hour after, depending on demand. A 'will-call' may be any time, depending on demand. In order to process your request to utilize the Paratransit service and determine eligibility, the following pages (1-4) must be completed and returned to Pine Bluff Transit for review. A determination of eligibility will be made from the information provided.

INSTRUCTIONS:

Applicant: Completely fill in the information required. 'Request for Professional Verification" will be faxed to your physician or health care official. After your application has been received, we will schedule you to come into our office for a personal interview. A personal interview is part of the application process. (Your application will be considered incomplete without the personal interview).

If you have any questions or need assistance in completing this request, please contact Pine Bluff Transit, Paratransit department at 543-5133 / Fax # 543-6975.

APPLICATION FOR ADA PARATRANSIT ELIGIBILITY

The information obtained in this certification process will only be used by Pine Bluff Transit for the provision of transportation services. Information will only be shared with other transit providers to facilitate travel in those areas. The information will not be shared with any other person or agency.

Fields marked with * must be completed or form will not submit.

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Please explain completely.","name":"How-does-this-disability-prevent-you-from-using-fixed-route-service","subtype":"textarea","className":"col-md-6"},{"type":"textarea","label":"Are there any other effects of your disability of which we need to be aware?","name":"Are-there-any-other-effects-of-your-disability-of-which-we-need-to-be-aware","subtype":"textarea","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"The following information will be used to ensure that an appropriate vehicle is utilized to provide you with transportation and that an accurate analysis of your trip requests can be made by Pine Bluff Transit.","className":"d-block"},{"type":"checkbox-group","label":"Do you use any of the following aids to mobility? (Check all that apply)","name":"Mobility-Aids","other":true,"className":"col-md-6","values":[{"label":"Manual Wheelchair","value":"Manual Wheelchair"},{"label":"Electric Wheelchair","value":"Electric Wheelchair"},{"label":"Power Chair or Scooter","value":"Power Chair or Scooter"},{"label":"Cane","value":"Cane"},{"label":"Crutches","value":"Crutches"},{"label":"Personal Care Attendant","value":"Personal Care Attendant"},{"label":"Guide Dog","value":"Guide Dog"}]},{"type":"checkbox-group","required":true,"label":"Do you require a personal care attendant when you travel using transit?","name":"Require-personal-care-attendant","className":"col-md-6","values":[{"label":"Yes","value":"Yes I require a personal care attendant"},{"label":"No","value":"No I don't require a personal care attendant"}]},{"type":"paragraph","subtype":"p","label":"Please mark the appropriate response to the following questions:","className":"d-block"},{"type":"checkbox-group","required":true,"label":"Can you travel 200 feet without the assistance of another person?","name":"Travel-200-feet-without-assistance","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes I can travel 200 feet without assistance"},{"label":"No","value":"No I can't travel 200 feet without assistance"},{"label":"Sometimes","value":"Sometimes I can travel 200 feet without assistance"}]},{"type":"checkbox-group","required":true,"label":"Can you travel 1/4 mile without the assistance of another person?","name":"Travel-14-mile-without-assistance","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes I can travel 1/4 mile without assistance"},{"label":"No","value":"No I can't travel 1/4 mile without assistance"},{"label":"Sometimes","value":"Sometimes I can travel 1/4 mile without assistance"}]},{"type":"checkbox-group","required":true,"label":"Can you climb three 12 inch steps without assistance?","name":"Climb-three-12-in-steps-without-assistance","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes I can climb three 12 inch steps without assistance"},{"label":"No","value":"No I can't climb three 12 inch steps without assistance"},{"label":"Sometimes","value":"Sometimes I can climb three 12 inch steps without assistance"}]},{"type":"checkbox-group","required":true,"label":"Can you wait outside without support for ten minutes?","name":"Wait-outside-without-support-for-10-minutes","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes I can wait outside without support for ten minutes"},{"label":"No","value":"No I can't wait outside without support for ten minutes"},{"label":"Sometimes","value":"Sometimes I can wait outside without support for ten minutes"}]},{"type":"paragraph","subtype":"p","label":"In order to allow Pine Bluff Transit to evaluate your request, it may be necessary to contact a physician or other professionals to confirm the information you have provided.  Please complete the following information and authorization form.","className":"d-block"},{"type":"radio-group","required":true,"label":"Physician, Healthcare Professional or Rehabilitation Professional who is familiar with my disability and is authorized to provide information to Pine Bluff Transit required to complete the certification.","name":"Physician-Healthcare-Professional-or-Rehabilitation-Professional-who-is-familiar-with-disability","className":"d-block","values":[{"label":"Physician","value":"Physician"},{"label":"Healthcare Professional","value":"Healthcare Professional"},{"label":"Rehabilitation Professional","value":"Rehabilitation Professional"}]},{"type":"text","required":true,"label":"Name of Physician or Other Healthcare Official","name":"Name-of-Physician-or-Other-Healthcare-Official","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Street Address of Physician or Other Healthcare 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Official","placeholder":"xxx-xxx-xxxx","name":"Phone-Number-of-Physician-or-Other-Healthcare-Official","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Fax Number of Physician or Other Healthcare Official","placeholder":"xxx-xxx-xxxx","name":"Fax-Number-of-Physician-or-Other-Healthcare-Official","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"I hereby certify that the information provided above is correct and authorize the release of additional information from the Healthcare Provider listed above in order to complete this certification.","className":"d-block"},{"type":"text","required":true,"label":"Signature","placeholder":"Disclaimer: By typing your name, you are signing this document.","name":"Signature","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"If other than applicant, what is your relationship to the applicant?","name":"If-other-than-applicant-what-is-your-relationship-to-the-applicant","className":"col-lg-4","subtype":"text"},{"type":"date","required":true,"label":"Date of Signature","name":"Date-of-Signature","className":"col-lg-4"}]