Handy Ride Application InstructionsAll applicants must submit a complete application which includes both forms(1) The Certification Questionnaire(2) The Professional Verification FormSTEP1STEP2COMPLETE The Certification QuestionnaireThe Certification Questionnaire should be filled out by the applicant orthe applicant’s advocate. The form must be filled out in its entirety. Itshould be signed by the applicant or the applicant’s guardian andanyone who assisted the applicant in completing the application.COMPLETE The Professional Verification FormThe Professional Verification Form must be completed by one of thefollowing professionals who are familiar with the applicant’s condition: Physicians or Psychiatrists; Occupational Therapists; Psychologists; Physical Therapists; Recreational Therapists; Registered Nurses (RN)To complete the Professional Verification Form1. Complete and sign the Authorization to Release Information.2. Send the Professional Verification Form to your designated professional.3. Wait for your professional to return the Professional Verification Form to you.Check back with your professional if you have not received the form back in atimely manner.SUBMIT Both Forms TogetherSTEP3Submit both the Certification Questionnaire and the ProfessionalVerification Form together to:Mail to:Fresno Area Express2223 “G” StreetFresno, CA 93706Fax to #(559) 457-1589Deliver in-person to:Handy Ride Center4488 N. BlackstoneManchester Transit Center3590 N. Blackstone1

STEP4In-Person AssessmentUsually the forms provide FAX Handy Ride Staff with all of theinformation needed to make a determination on eligibility. Sometimeshowever more information is needed. When this happens an applicantmay be asked to come in for an “in-person assessment.”This assessment may include: A conversation about the applicant’s current mobility. The FAX Mobilityevaluator will talk with you about how you currently get around. A walk outside. This will help determine things such as physical ability to getto the regular fixed-route bus as well as memory and landmark recognition.Please note that applicants who need to come in for in-person assessments willstill have their applications processed within 21 calendar days.Common IssuesIn order to make a determination within 21 calendar days the FAX Handy RideCenter must have a complete application. There are several things which maycause an application to be incomplete. By double checking these things PRIORto submitting your application you may avoid delays in processing.1. One of the forms is missing. Your application must contain both theCertification Questionnaire and the Professional Verification. Please ensureboth are submitted together.2. One of the forms is not signed. Both the Certification Questionnaire andthe Professional Verification must be signed. If either the applicant or theprofessional forgets to sign the form it is considered incomplete.3. The professional credentials are missing. Professionals must include theirtitles and credentials when signing the Professional Verification.If FAX has not made a determination of eligibility by a date 21 days after thesubmission of an individuals completed application, the applicant will be treatedas eligible and provided service unless and until FAX denies the application.2

DATE RECVD:FOR FAX STAFF ONLY:EXPIRATION DATE:Certification QuestionnaireQuestions about this form?Call FAX Handy Ride at (559) 621-5796, or California Relay at 711 for TTY.Complete all parts of the form. Forms that are not fully completed will bereturned, which will delay your eligibility determination.PART 1Applicant DataPlease print or typeName:MaleFirstBirth Date:Middle Initial//Last.Street Address:Apt.#:City:Day Telephone: (FemaleZip Code:)Evening Telephone: ()Mailing Address (if different from above)Street Address:Apt.#:City:Zip Code:Emergency Contact PersonName:Day Telephone: (Relationship:)Evening Telephone: ()Are you currently enrolled in the FAX Special Rider program?YesNoHave you ever been enrolled in the FAX Handy Ride program?YesNoDo you have a California ID card or California driver's license?YesNo3

What is your disability?Explain how your disability prevents you from independently using the regularcity bus.1. Which of the following assistive devices, if any, do you use?(Please check all that apply.)CanePowered WheelchairWhite CanePowered Scooter/CartWalkerCommunication AidCrutchesService AnimalOther (please describe):Manual WheelchairProsthesisPortable OxygenIf you selected Wheelchair or Scooter, would you prefer/need to use the devicewhile riding in FAX Handy Ride Vehicles?YesNoSometimes4

2. Are you able to travel in an automobile?YesNo3. If you use a wheelchair or scooter:Is it more than 33 inches wide?YesNoIs it more than 51 inches long?YesNoIs the combined weight of device and occupant more than 800 pounds?YesNo4. Does your health condition/disability require you to use Handy Ride service:PermanentlyTemporarilyWeek(s)Month(s)5. Does your health condition/disability change from day to day in ways thatoccasionally disrupts your ability to use regular-route city bus service?YesNoIf yes, please explain:PART 2Questions about using regular-route public transitComplete Part 2 even if you are unable to use regular-route city bus service.This information will assist us in determining how your disability/health conditionaffects your ability to use regular-route city bus service.7. Do you now independently use regular-route city buses?YesNoSometimesYes, but only with an attendantIf “Yes” or “Sometimes,” how many times? per week per monthWhich of the following best describes how you use regular-route city buses?To travel to and from one destination onlyTo travel to and from a few destinationsTo travel to and from many different destinations8. Have you ever had training to use the regular-route city buses?YesNo9. What is the maximum distance you are able to travel without the assistanceof another person?less than 1 block1-3 blocks4-6 blocksmore than 6 blocks( 110 yards)(110-330 yards)(440-660 yards)(more than 661 yards)10. I can wait for a regular-route city bus (check all that apply):Only if there is a bench or shelterUp to 15 min.More than 15 min.5

11. Please check all the categories below as they relate to your ability to useregular-route city buses:I am:Yes No SometimesA. Able to tolerate hot or cold weather (rain, humidity)B. Able to recognize destinations, bus stops, orlandmarksC. Able to tolerate air pollution (smog, fumes,perfume)D. Free from night blindness (bright light, low light)E. Able to recognize printed informationF. Able to hear and process spoken words or auditoryinformation (background noise)G. Able to communicate needsH. Able to follow directionsI.Able to deal with unexpected situations or changesin routine (example: bus detours)J. Able to safely and effectively travel throughcrowded and/or complex facilitiesK. Able to recognize and navigate curbs, drop-offs,curb cuts and other barriersL. Able to travel independently along sidewalks andother pedestrian waysM. Able to cross streets independentlyN. Able to find the correct bus stopO. Able to identify the correct bus (single or multiplebuses during a single trip)P. Able to get on and off a bus using the lift ifnecessaryQ. Able to deposit fare into the fare box or show buspassR. Able to get to a seat/wheelchair positionS. Able to ride in a standing positionT. Familiar with what to do if I miss my bus6

If you checked “No” or “Sometimes” to any of the items in question 11,please explain:Please list the addresses commonly traveled to:Street Address:Apt.#:City:Zip Code:Street Address:Apt.#:City:Zip Code:Street Address:Apt.#:City:Zip Code:Street Address:Apt.#:City:Zip Code:7

PART 3Applicant Signature"The information you provide is confidential and will be treated as such. It willonly be shared with agencies involved with FAX’s eligibility determinationprocess and other transit providers to facilitate travel in those areas, and will notbe provided to any other person or agency, except as provided by the CaliforniaPublic Records Act." If you are determined ADA paratransit eligible, informationabout your eligibility status will be entered into a database maintained by FresnoArea Express.I certify that all information on this application form is accurate. I understandthat misinformation or misrepresentation of facts will be cause fordisqualification or rejection of my ADA eligibility. I also understand thatadditional information relating to my health condition or disability may berequired to determine eligibility. This information may be obtained through an inperson assessment or by requesting information from a professional whounderstands my health condition or disability. Additional information will berequired only when the information provided on the application form does notclearly determine ADA paratransit eligibility.Applicant’s Signature: Date:* If the applicant is not his/her own guardian, the following information about theguardian is required:Guardian’s Name:FirstMiddle InitialLastDay Phone: ( )Guardian’s Signature: Date:* If someone other than the applicant or the applicant’s guardian is preparingthis form, please provide the following information about the preparer:Name:FirstMiddle InitialLastRelationship to applicant:Day Phone: ( )Preparer’s Signature: Date:8

Handy Ride Eligibility ApplicationProfessional Verification1. Complete and sign the “Authorization to Release Information”.2. Send to your designated professional.3. Wait for the professional to return the Professional Verification Form to you.Check back with your professional if you don’t receive your information.4. Put your Certification Questionnaire and Professional Verificationforms together and send to:Fresno Area Express2223 “G” Street, Fresno, CA 93706Facsimile: (559) 457-1589SECTION AAuthorization to Release Information(when complete send to the professional you named)Applicant’s Name:Date of Birth: / /Applicant’s Address: Apt.#City: State: Zip Code:Applicant’s Telephone Number: ( )I authorize the following professional to release FAX Handy Ride specificinformation as requested. It is my understanding that the information releasedwill be used solely to determine my ADA paratransit eligibility. I understandthat I may revoke this authorization at any time. Unless revoked, this form willallow that professional listed below to release information described for sixmonths after the date appearing below. All healthcare information will be keptconfidential.Name of Professional: Title:Applicant’s Signature: Date:Guardian’s signature required if the applicant is not his/her own guardian,Guardian’s Signature: Date:9


SECTION BMetro Mobility Professional Verification FormThis section can only be completed by a licensed professional listed on page 1 of theinstructions.Dear Health Care Professional:The Federal Law is very specific about ADA Para-transit eligibility. You arebeing asked to provide information regarding this individual’s disability.Eligibility is restricted to individuals who,1. As a result of their disability, cannot board, ride, or disembark from a regularfixed route bus.2. Have a specific impairment related condition which prevents them fromgetting to or from a bus stop.PLEASE NOTE: This does not include persons who find it difficult or uncomfortableto get to and from bus stops.In providing information you should consider only the presence of a disability or healthcondition and not the applicant’s age or economic status.You will be asked to include your credentials on page 13.GENERAL INFORMATION (Must be completed for all applicants)Describe diagnosed disability you are currently treating this individual for and thefunctional limitations of this impairment:Date of onset / / Date of last visit / /How long have you worked with individual? Since / /Is disability temporary or permanent ?If permanent, is disability progressive?YesNoIf temporary please give best estimate of rate of recoveryDo temperature extremes affect the individual? (Ex. Heat index of more than 85degrees or wind chill less than 32 degrees)YesNoIf yes, how so?Please list all medicationsIs this individual compliant with taking medications?11YesNo

Can the individual currently use regular route public transportation? (all buses areequipped with wheelchair lifts)YesNoNot SureDoes the individual’s health condition/disability require they travel with someone toassist and/or supervise them?YesNoIs the individual’s judgment impaired?Is behavioral inhibition impaired?YesCan the individual walk?NoYesYesNoNoDoes the individual use a wheelchair or mobility aid?YesNoPlease listHow long has the individual been using the device(s)?What is the maximum distance the individual is able to travel without the assistance ofanother person?less than 1block1- 3 blocks4-6 blocksmore than 6 blocks( 110 yards)(110-330 yards)(440-660 yards) (more than 660 yards)Is/ Can/ Does the individual:AYes No SometimesAble to live independentlyB. Able to seek and ask directionsC. Able to process informationD. Able to follow routines (consistency)E. Have basic coping skillsF. Have basic judgment skillsG. Have basic problem solving skillsH. Have basic orientation skills (person, place, time)I.Have any concentration limitationsJ. Have any short or long term memory limitationsK. Have basic orientation skill (person, place, time)VISUAL IMPAIRMENT(Please complete if applicable to patient’s disability)Please provide visual acuity measurements and visual field readings for both eyes.OS OD12

EMOTIONAL/BEHAVIOR ISSUESDoes the individual experience any of the following:Auditory hallucinationsVisual hallucinationsDisassociationDelusionsDoes this prevent the individual from being oriented to person, place, and time?YesNoIs the individual currently being treated for any of the following:AnxietyDepressionPanic attacksSchizophreniaOther:For anxiety panic attacks please indicate on average the frequency and length ofpanic attacks.per dayper weekper monthper yearapprox. durationPLEASE PRINT SO THAT WE MAY CONTACT YOU IF NEEDEDName of Professional:Title: Professional License # :Address:City: State: Zip Code:Telephone Number: Fax:Doctor/Health Care Professional Signature:Please provide any additional information which may assist us in determining thisapplicant’s eligibility:HandyRide staff will make the final determination on the applicant’s eligibility.Handy Ride staff will make the final determination on the applicant’s eligibility.13

Fresno Area Express (559) 457-1589 Handy Ride Center 2223 "G " Street .