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Cedar Rapids Transit
ADA Paratransit Application
http://cr-intranet/citynet/click_thru.asp?ContentId=2386
Attached is an application for you to complete in order to receive ADA paratransit service. If you have a
disability that prevents you from using the fixed-route city bus service, you may be eligible for ADA
paratransit service administered by Cedar Rapids Transit and operated under contract by Linn County
LIFTS. If you are currently a Linn County LIFTS client, it will still be necessary for you to complete an
application to be certified.
Public transit systems are required by the Americans with Disabilities Act (ADA) to establish a process for
determining ADA paratransit eligibility. The goal of the process is to ensure that only persons who meet the
ADA criteria are regarded as eligible. Eligibility is strictly limited to any person with a disability that is unable
to use the regular fixed-route city bus system. Diagnosis of a disability does not establish eligibility. What is
needed is a determination of whether the person can use the fixed-route city bus system under given
circumstances. The person’s physical and mental abilities in relation to getting on and off a bus, riding the
bus, and traveling to or from a bus stop will be considered when determining eligibility for paratransit
services. A person’s age, income, inability to drive, travel preference or inconvenience are not considered
qualifying factors. In addition, the service is only provided within the city limits of Cedar Rapids, Marion and
Hiawatha.
There are three types of ADA paratransit eligibility:
. Full – if your disability prevents you from using the fixed-route city bus system for any trips.
. Conditional – if you can use the fixed-route city bus system under certain circumstances, but
need the ADA paratransit service for specified trips.
. Temporary – if your disability does not require a permanent need for ADA paratransit service.
To enable us to determine your eligibility, it is your responsibility to complete Part 1 and have your physician
or health care professional complete Part 2 of this application. Please be as specific as possible. The
questions are meant to determine the functional abilities you have and under what circumstances you might
be able to utilize the wheelchair-accessible fixed-route city bus system. If you don’t believe there is enough
space to answer your questions, feel free to attach a sheet to the back of this application. Please number
your answers to match the question so we know what response belongs to which question. Both sections
must be filled out and the entire application submitted to Cedar Rapids Transit to be considered a complete
application. An incomplete application will be returned to you and will delay your eligibility determination.
Completed applications will be processed as soon as possible and you will receive written notification of the
decision. If you have not received a response within 21 days after mailing your completed application or if
you have any questions regarding this process, please call (319) 286-5540 for assistance.
Please mail your completed application to the following address:
Cedar Rapids Transit
Attn: ADA Paratransit Service Application
427 8th St NW
Cedar Rapids, Iowa 52405
Part 1 – Applicant Information
All questions must be answered by the applicant (only one applicant per form). Incomplete or illegible
forms will be returned. Please circle appropriate answers below and give explanations where indicated.
Applicant Name: ________________________________________ Birthdate: _________________
Address: _________________________________________________________________________
Address is a: Residence Group Home Assisted Living Apartment Care/Nursing Facility
Telephone: __________________________ Alternate Phone: __________________________
1. Please describe your current disability: (Be specific and list all applicable disabilities)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
2. How does this disability prevent you from using the fixed-route city bus system? Please keep
in mind that all fixed-route city buses are wheelchair accessible.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
3. Is your disability: Permanent Temporary
If temporary, what is the expected duration? _______________________________________
4. If your disability changes from day to day, please explain how:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
5. Does your disability prevent you from getting to or from a fixed-route bus stop? Yes No
If yes, please explain: _________________________________________________________
___________________________________________________________________________
6. How many blocks can you travel or walk? _________ Blocks
7. Do changes in weather prevent you from getting to or from a bus stop? Yes No
If yes, list specific weather conditions and its impact on your mobility: ____________________
___________________________________________________________________________
8. Is there a physical barrier that, when combined with your disability, might prevent travel to or
from the bus stop? If yes, please list: (Examples: no sidewalks, no crosswalks/lights,
no curb cuts, steps) ___________________________________________________________
___________________________________________________________________________
9. Are you prevented from traveling to or from a bus stop for any of the following reasons?
(Please circle all that apply):
Inability to negotiate hilly terrain Allergic/environmental sensitivities
Night blindness Hyper-fatigue or frailty
Extreme sensitivity to weather conditions Inability to cross busy intersections
Other (please explain): __________________________________________________
10. Can you wait ten minutes alone at a bus stop? Yes No
(If no, please explain) _________________________________________________________
11. Can you climb three steps to get into a bus? Yes No
12. Can you board a bus with a “kneeling” feature which lowers the height of the first step? Yes No
13. Can you follow written instructions? Yes No Oral instructions? Yes No
14. Can you use the telephone or TTD to make calls? Yes No
15. Are you able to identify the bus you need? Yes No
16. Are you able to detect curbs, curb cuts, sidewalks, etc? Yes No
17. Do you have a visual impairment that prevents you from riding the bus? Yes No
18. Do you use a mobility aid? Yes No
(If yes, please circle all of the following mobility aids you might use):
Manual wheelchair Electric wheelchair Power scooter
Walker Support cane White cane
Oxygen tank Crutches Guide/assistance animal
Ambulatory, but must use lift to board vehicle Other _______________________
19. If you use a wheelchair or scooter, what are its physical dimensions two inches above the floor,
including foot or head extensions (in inches)? Note: a common wheelchair does not exceed 30
inches in width or 48 inches in length when measured two inches above the ground, and does
not weigh more than 600 pounds occupied.
Width __________ Height __________ Length __________ Occupied Weight __________
20. Do you require a Personal Care Attendant (PCA) when you travel? Note: A PCA is someone
who is designated or employed by a person to provide personal assistance; it is not a companion.
Yes No Sometimes
21. Do you currently ride the fixed-route city bus system? Yes No
If yes, how often ________ / week.
22. Have you ever received travel training on the fixed-route city bus system? Yes No
23. Would you be interested in travel training? Yes No
24. Would you like to receive information about the fixed-route city bus system? Yes No
Please provide a contact name and number of a relative or friend in case we are unable to reach you:
Name: __________________________________ Relationship: ____________________________
Telephone: ______________________________ Alternate Phone: _________________________
I hereby certify, to the best of my knowledge, that the information I have provided in this application is
correct and true. I agree to notify Cedar Rapids Transit of any changes in my status, which may affect
my eligibility to use this service. In addition, I hereby authorize my health care professional to provide
any additional information to Cedar Rapids Transit personnel as needed or requested to make their
eligibility determination.
Signature of applicant: __________________________________ Date: ____________________
If you have completed this application on the applicant’s behalf, you must provide the following information.
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
Daytime telephone: ______________________ Relationship to applicant: ____________________
Part 2 - Request for Professional Verification
(To be completed by a licensed Physician or Health Care Professional)
You are being asked by the applicant named in Part 1 to provide information regarding their disability
and its impact on their ability to use the fixed-route city bus system operated by Cedar Rapids Transit.
The Americans with Disabilities Act (ADA) requires public transit systems to provide paratransit service
to persons who, due to a disability, are unable to use the fixed-route city bus system. The goal of the
ADA paratransit eligibility process is to ensure that only persons who meet the ADA criteria are regarded
as eligible.
Diagnosis of a disability does not establish eligibility. What is needed is a determination of whether the
person can use the fixed-route city bus system under given circumstances. Please keep in mind that all
of our fixed-route city buses are equipped with wheelchair lifts/ramps. The person’s physical and mental
abilities in relation to getting on and off a bus, riding the bus, and traveling to or from a bus stop will be
considered when determining eligibility for paratransit services. A person’s age, income, inability to drive,
travel preference or inconvenience are not considered qualifying factors. The information that you provide
will allow Cedar Rapids Transit to make an appropriate eligibility determination for this applicant. Thank you
for your cooperation and assistance.
Applicant’s Name _____________________________
Capacity in which you know the applicant: ____________________________________________________
Please identify the applicant’s disability and describe the impacts or limitations to mobility:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Is this condition temporary? Yes No If yes, expected duration ____________________________
If the applicant has a visual impairment, please identify the extent of impairment and describe how it
prevents their use of the fixed-route city bus system: ___________________________________________
_____________________________________________________________________________________
If the applicant has a cognitive disability, please identify the extent of impairment and describe how it
prevents their use of the fixed-route city bus system: ___________________________________________
_____________________________________________________________________________________
In your professional opinion, is this person able to ride the fixed-route city bus system? Yes No
I hereby certify that the above information is correct and true.
Physician’s Signature (or stamp) ________________________________ Date _____________________
Physician’s Name ____________________________________________ Telephone ________________
Name of Practice ____________________________________________ Email ____________________
Address of Practice _____________________________________________________________________
City _______________________________________ State ___________ Zip Code _________________
Medical License # ____________________________________________ State ____________________
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