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4. Do you require the assistance of a Personal Care Attendant (PCA) when you travel out- side your home?

Yes No

5. Do you travel with a service animal (Guide Dog, etc.)?



Part 4. Functional Abilities

6. Do you currently use Palm Tran fixed-route bus service?



7. If you currently use Palm Tran fixed-route bus service, which routes do you use? __________________________________________________________________________

8. When was the last time you used the Palm Tran fixed-route bus service? __________________________________________________________________________

9. When are you UNABLE to use the Palm Tran fixed-route bus? (please indicate below the following situations that apply to you)

I can use Palm Tran regular bus service for some trips, but other times there are barriers that prevent me from using the bus.

I have difficulty understanding and/or remembering all of the things I would have to do to find my way to and from the bus.

I have difficulty getting to and from bus stops because I become disoriented easily.

I can only get to and from bus stops if the distance is not too great and there are curb cuts and sidewalks on the route.

I can only wait at Palm Tran bus stops if there is a bench or shelter.

The severity of my disability can change from day to day. I can ride the bus only when I am feeling good.

I cannot cross busy streets and intersections.

I have difficulty or cannot climb stairs and can only board a Palm Tran bus if it has a lift or ramp.

I have a health condition and cannot ride the bus if the walk is too far or if the weath- er is too hot.

I can never use the Palm Tran bus service by myself. 5

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