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SECTION D:  PROFESSIONAL ASSESSMENT

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?

 Yes  No

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?      

 Permanent  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

Page 8

Revised 6/14/07

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