ADA Paratransit Certification Application
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Request for Professional Verification

The attached authorization form has been submitted by __________________________, Who has indicated that you can provide information regarding his/her disability and its impact upon his/her ability to utilize fixed route services. Federal law requires Citilink to provide paratransit services to persons who cannot utilize available fixed route services.The information you provide will allow us to make an appropriate evaluation of this request and its application to specific trip requests.

Capacity in which you know the applicant:__________________________

* * * * * * * * * * * * * * * *

Medical diagnosis of condition causing disability:____________________

____________________________________________________________

Is the condition temporary?______  If yes, expected duration:______ 

If the person has a disability effecting mobility, is the person:

Able to walk 200 feet without assistance?
Yes______  No______  Sometimes______ 

Able to walk______  mile without assistance?
Yes______  No______  Sometimes______ 

Able to walk______  mile without assistance?
Yes______  No______  Sometimes______ 

Able to climb three 12-inch steps without assistance?
Yes______  No______  Sometimes______ 

Able to wait outside without support for 10 minutes?
Yes______  No______  Sometimes______ 

Does this person use any mobility aids?
If so, what? ____________________________________________

Does this person have a visual impairment? Yes______     No______ 

Visual acuity with best correction:
right eye______  left eye______  both eyes______ 

Visual fields:
right eye______  left eye______  both eyes______ 

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