This section of your application must be completed, signed and dated by a professional who is familiar with your disability or health condition. Information obtained is confidential and will be used to determine if you have the functional ability to use Valley Metro fixed route service. Please use common language and print or type clearly.
Can the applicant use public fixed route service?
Specify how the applicant’s disability or health condition affects his/her ability to use public fixed route service?
Is the applicant’s disability or health condition permanent or temporary?
If temporary, how long will services be needed?________________________
Please indicate the applicant’s ability to perform the following functions:
Understand directions needed to complete a trip? Yes No
Identify the correct bus stop? Yes No
Travel independently to and from nearest transit stop? Yes No
Wait standing 15 minutes at a stop? Yes No
Wait if seated? Yes No
Get on/off a bus without assistance? Yes No
Get on/off if a kneeling device/lift is deployed? Yes No
Can the applicant benefit from travel training? Yes No
Walk 200 feet without assistance? Yes No
Walk 1/4 mile without assistance? Yes No
Walk 3/4 mile without assistance? Yes No
Safely and effectively travel through crowded areas? Yes No
Does applicant use any mobility aids? Yes No
If so, what type?____________________________________________________
The applicant’s disability or health condition is currently:
Under Control Not Under Control Improving