HomeMy WebLinkAbout11/16/2023 - Disability Advisory Board - Agenda - Regular MeetingDisability Advisory Board
REGULAR MEETING
Zoom – See Link Below
1. CALL TO ORDER
2. ROLL CALL
3. AGENDA REVIEW
4. CITIZEN PARTICIPATION
5. APPROVAL OF MINUTES
a. September 21, 2023
6. GUEST PRESENTER: Katlyn Kelly, DAR Program Manager – Dial-a-Ride
7. NEW BUSINESS
8. OLD BUSINESS
a. 2024 Work Plan – Due November 30
Participation for this Disability Advisory Board Meeting will be held via Zoom only using
this link: https://fcgov.zoom.us/j/98185571735 Meeting ID: 981 8557 1735
Online Public Participation:
The meeting will be available to join beginning at 5:30 pm, August 17, 2023. Participants
should try to sign in prior to the 5:30 pm meeting start time, if possible. For public comments, the
Chair will ask participants to click the “Raise Hand” button to indicate you would like to speak at
that time. Staff will moderate the Zoom session to ensure all participants have an opportunity to
address the Board or Commission.
To participate:
• Use a laptop, computer, or internet-enabled smartphone. (Using earphones with a
microphone will greatly improve your audio).
• You need to have access to the internet.
• Keep yourself on muted status.
This information is available in Spanish or other language at no cost to a person who would like
this information translated to or communicated in Spanish or other language. Please call 970-
232-0512 or cmenendez@fcgov.com to make a request for information in other languages.
Esta información está disponible en español u otro idioma, sin costo para la persona que le
gustaría esta información traducida o comunicada en español u otro idioma. Favor llame al
970.232.0512 or cmenendez@fcgov.com para solicitar información en otros idiomas.
Auxiliary aids and services are available for persons with disabilities. TTY: please use 711 to call
970.416.4254
Disability Advisory Board
REGULAR MEETING
b. B&C Inputs for City’s 2024 Strategic Plan – Due November 17
9. OTHER BUSINESS/UPDATES
a. Awards Ceremony Debrief
10. FUTURE AGENDA REVIEW
11. ADJOURMENT
DISABILITY ADVISORY BOARD
REGULAR MEETING
Thursday, September 21, 2023 – 5:30 PM - 7:30 PM
Meeting held only through Zoom: https://fcgov.zoom.us/j/98185571735
Contact: mclark@fcgov.com or 970-416-4312
1. CALL TO ORDER: 5.32 p.m.
2. ROLL CALL
a. Board Members Present – Scott Winnegrad, Jaclyn Menendez, Linda Drees,
Mandy Morgan, Sheila Hammons, Rachel Knox-Stutsman, Joseph Tiner,
Evan Shockley
b. Board Members Absent – Terry Schlicting
c. Staff Members Present – Claudia Menendez, Equity Officer; Office of Equity
and Inclusion, Melanie Clark, Executive Admin Assistant; Office of Equity and
Inclusion
d. Guest(s) – MacKenzie Lowe, Larimer County ADA Coordinator; Brad Buckman,
City Engineer – Accessibility on Linden Street
3. AGENDA REVIEW
4. CITIZEN PARTICIPATION
5. APPROVAL OF MINUTES
a. July 20, 2023
Board member Scott Winnegrad explained that a note regarding a comment
made by Rupa Venkatesh wasn’t exactly clear and asked for it to be removed.
Board member Joe Tiner requested a change in wording from wheelchair
bound to wheelchair user.
Board member Scott Winnegrad motioned to approve the July minutes as
amended. Board member Joe Tiner second the motion.
b. August 10, 2023
Board member Scott Winnegrad noted under Old Business there was a typo in
the 5th paragraph.
Board member Scott Winnegrad motioned to approve the August minutes as
amended. Joe Tiner second the motion.
6. Guest Presenter
a. Brad Buckman, City Engineer – Accessibility on Linden Street
Brad Buckman, City Engineer, stated that he wanted to offer a field trip of the
Linden Street project that was completed about a year ago. The purpose of
the project was to open up Linden Street between Maple and Jefferson for
more of an active modes space. He shared a picture of a pedestrian access
location that constrains down to about 5.5 feet. He asked if Board members
wanted to visit the location and to provide feedback on changes.
Board member Scott Winnegrad questioned how snow removal is with the
tree grate and whether it posed a problem with ice buildup. Brad will check in
with the Parks Department, but he hasn’t heard of any issues.
Board member Joe Tiner inquired about the timeline for feedback and taking a
tour. Brad stated that they don’t really have a timeline. He offered that folks
can reach out to him or Ginny Sawyer to set up a time for a field trip.
Board member Rachel Knox-Stutsman wondered about the clearance
between the tree and the fences. Brad stated that it is approximately 5.5 feet.
She asked if the paving bricks were flat, Brad stated that they are not perfectly
flush, but are flat.
Claudia Menendez, Equity Officer asked if any complaints have been made.
Brad stated that some questions have been brought up by a couple of our
Councilmembers.
Scott Winnegrad questioned what the best way to move forward would be.
Claudia Menendez, Equity Officer recommended that they schedule a time for
all of them to meet at the location or have a deadline for each member to visit
the area on their own.
Scott reiterated that his biggest concern is the maintenance of the area during
the winter months.
Board members discussed visiting the area on their own and inviting Brad
back to the meeting in November to follow up.
7. NEW BUSINESS:
a. UCHealth Presentation Request
Kristen Bene with UCHealth emailed to request a 30-minute virtual
presentation for staff and clinicians. Their goal is to better support persons of
all diverse backgrounds that might engage with their clinic.
UCHealth is particularly interested in hearing common issues facing
community members who have disabilities, common areas of discrimination or
inequity and opportunities for how clinicians and the healthcare system can
better support people.
Staff Liaison, Melanie Clark explained that she and Claudia discussed
recommending this be a panel discussion to allow a diversity of voices to be
heard from.
Board member Joe Tiner liked the idea of this being a panel.
Board member Linda Drees stated that part of their mission is to educate on
disabilities. She questioned what their top 5 issues of concern are and how
they address those.
Board member Jaclyn Menendez does like the idea of whatever is prepared
as a group to share that this information can be used in the future for other
training opportunities.
Board members discussed different ideas for providing a presentation or
training. One suggestion was to invite UCHealth in DAB meetings on a
quarterly basis or yearly basis to get them involved.
Board members discussed inviting UCHealth to attend the February DAB
meeting.
Scott will reach out to Kristen Bene with UCHealth to discuss what they are
hoping to get out of their meeting with DAB and to invite them to future DAB
meetings.
Scott Winnegrad motioned to invite UCHealth to the DAB meeting on a regular
basis. Joe Tiner second the motion.
b. B&C Inputs for City’s 2024 Strategic Plan
Board members will review handouts provided by Melanie and will discuss at
the November meeting.
c. Restrictions for B&C Under Fair Campaign Practices
d. Changes to B&C Terms & Recruitments
Staff Liaison, Melanie Clark will send an email to board members notifying of
these changes.
8. OLD BUSINESS: Dial-a-Ride
9. OTHER BUSINESS/UPDATES:
a. Work Plan Due November 30
b. DAB Community Awards Nominations
Board members reviewed and discussed nominee selections.
Scott Winnegrad motioned to approve the nominees as discussed. Board
member Jaclyn Menendez second the motion.
10. FUTURE AGENDA REVIEW
a. B&C Inputs for City’s 2024 Strategic Plan
b. 2024 Work Plan
11. ADJOURNMENT
a. 7:34 p.m.
Minutes approved by the Chair and a vote of the Board/Commission on XX/XX/XX
X/XX/XX– MINUTES Page 1
0
0.2
0.4
0.6
0.8
1
1.2
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ More than 3/4 Mile
□ 1/4 Mile (3 Blocks)□ 1/2 Mile (5 Blocks)
If you selected "temporarily" what
is your Anticipated Recovery Date
(mm/dd/yyyy)
□ Sometimes □Temporarily □ N/A
Chart Title
10. If you currently use the Transfort bus do you:□ Travel only to places that you are familiar with or have been trained to go?
□ Use the City bus to travel independently throughout the City?
Transfort/Dial-A-Ride Eligibility Application
APPLICATION FOR ADA PARATRANSIT SERVICES
WHO MAY BE ELIGIBLE FOR DIAL-A-RIDE SERVICES?
Dial-A-Ride provides paratransit transportation to people who are eligible under the Americans with
Disabilities Act (ADA). The ADA requires transit agencies that have fixed-route bus service provide
complementary paratransit service to individuals with disabilities whose disability in combination with
functional abilities prevents them from being able to use a fixed-route bus.
People who wish to qualify for the City of Fort Collins paratransit program must complete and return the
application form to Transfort / Dial-A-Ride. This includes completing and signing the attached "Authorization
to Release Medical Information" form, and return it with your application.
Please note that residency is not required to apply for service.
REQUIREMENTS FOR DIAL-A-RIDE ELIGIBILITY:
The ADA includes two requirements for Dial-A-Ride eligibility:
1. You must have a disability; and,
2. Your disability must prevent you from using the Transfort fixed route bus service.
Dial-A-Ride eligibility is not based on:
• A g e
• A disability or medical diagnosis
• A lack of Transfort fixed route bus service in an area
• An inability to drive
• Personal finances
To view the categories of eligibility under the ADA regulations, please review the Dial-A-Ride Users Guide.
HOW IS ELIGIBILITY DETERMINED?
When your completed application and signed Medical Release form are received, we will send a Health Care
Provider/Professional (HCP) Verification form to the HCP that you identified on your application to verify your
disability or illness. It is important that you list the HCP who will be most familiar with your disability or illness.
Once the HCP form has been received by Dial-A-Ride, eligibility staff will begin to process your completed
application. Applications are not complete until the HCP form has been completed and received by Dial-A-
Ride. Incomplete applications may cause an interruption in the eligibility process. Eligibility for services is
determined by information you provide and information we obtain from your health care provider.
Dial-A-Ride will process your completed application within 21 calendar days of receipt of the completed HCP
form. If a decision is not made within this time, presumptive eligibility will be granted until a decision can be
made.
You will be notified of the eligibility determination by letter, mailed to the mailing address you provided. If you
are determined eligible, you will receive a Dial-A-Ride Users Guide with information about how to use the
service.
Page 2 of 10
Transfort/Dial-A-Ride Eligibility Application
Transfort / Dial-A-Ride Phone: (970) 224-6002
6570 Portner Road Fax: (970) 207-7969
Fort Collins, Colorado 80525 Monday - Friday 8 a.m. to 5 p.m.
INSTRUCTIONS FOR COMPLETING THE APPLICATION:
1. Answer all questions completely and to the best of your ability.
2. Be sure to sign the application. Incomplete and/or unsigned applications may be returned to you.
3. Complete and sign the Medical Release Form. Incomplete or unsigned Medical Release Forms may be
returned to you.
4. Transfort staff may reach out to request additional information to complete the eligibility determination.
Mail or fax completed applications to the address listed below:
Please contact Dial-A-Ride at (970) 224-6002 if you need this application in an alternative format or if you
have any other questions about the eligibility process, including eligibility information or renewals, application
status, or visitor status requests.
There are no fees associated with the application process. Fees incurred such as transportation and mailing
may be reimbursed by sending a written request with a receipt or invoice to the address above. Fees will be
verified and reimbursed within 14 days of receipt of the request.
Page 3 of 10
Transfort/Dial-A-Ride Eligibility Application
□ New
M.I.
Gender
Work Phone (xxx)xxx-xxxx
Apt/Unit No.
Apt/Unit No.
M.I.
Work Phone (xxx)xxx-xxxx
Apt/Unit No.
□ YES □ NO
Relationship to Applicant
Home Phone (xxx)xxx-xxxx Cell Phone (xxx)xxx-xxxx
Address
City State Zip Code
5. Are you currently a Colorado State University student, faculty,
or staff?
Is this a new application or recertification?□ Recertification
4. Who may act on your behalf with Dial-A-Ride (for example, schedule or cancel trips)?
2. Emergency Contact Information
Last Name First Name
Cell Phone (xxx)xxx-xxxx
1. Applicant Information
Address
Zip Code
Home Phone (xxx)xxx-xxxx
City State
SECTION 1: BASIC INFORMATION
Last Name First Name
Date of Birth (mm/dd/yyyy)Email Address:
City State Zip Code
Mailing Address (if different from above)
Page 4 of 10
Transfort/Dial-A-Ride Eligibility Application
□Temporarily □ N/A
2. Does your condition/disability impact your ability to use the Transfort bus system:
For any selection besides always, please explain:If you selected "temporarily" what is
your Anticipated Recovery Date
(mm/dd/yyyy)
SECTION 2: FIXED ROUTE BUS
1. Dial A Ride is for individuals with a disability that prevents them from using the Transfort bus
system.
Do you have a health condition or disability that may prevent you from independently using Transfort bus
service? If so, please briefly explain.
□ 3/4 Mile (8 Blocks)□ More than 3/4 Mile
Please estimate how many minutes this would take:_____________
6. Please explain any other barriers or circumstances that prevent you from accessing bus stops or
using the Transfort bus system. Examples may include lack of accessible sidewalks, lighting,
weather conditions, busy intersections, unfamiliar locations, etc.
□Always □ Sometimes
Please answer the following questions considering the days when your condition is most
limiting.
These questions are intended to understand your ability to use the Transfort bus system.
4. What is the furthest distance to a bus stop or transit center you could reasonably travel to without
the assistance from another person?
□ Less than 200 feet □ 1/4 Mile (3 Blocks)□ 1/2 Mile (5 Blocks)
Page 5 of 10
Transfort/Dial-A-Ride Eligibility Application
7. Do you currently use Transfort bus service? □ YES □ NO
If YES, what routes do you typically use? ____________________________________________
How often do you use fixed-route service?___________________________________________
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
10. If you currently use the Transfort bus do you:
□ Travel only to places that you are familiar with or have been trained to go?
□ Use the City bus to travel independently throughout the City?
9. To understand your ability to use the Transfort bus system, please check "YES" or "NO" to the
following questions:
Are you able to use a bus route schedule to determine the correct bus
and locate bus stops?
Are you able to identify the correct bus to take when there are multiple
buses servicing a stop or transit center?
Are you able to independently board/de-board a bus that is wheelchair
accessible?
Are you able to wait at a non ADA accessible bus stop WITH seating?
Are you able to wait at an ADA-accessible bus stop WITH seating?
Are you able to wait at an ADA-accessible bus stop WITHOUT seating?
Are you able to wait at a non ADA-accessible bus stop WITHOUT seatin
SECTION 2 CONTINUED
8. Would you be interested in learning about travel training to use
Transfort buses?
Page 6 of 10
Transfort/Dial-A-Ride Eligibility Application
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
Is your visual impairment: □ Degenerative □ Stable □ Otherwise Changing
Are you able to deal with unexpected situations or changes in routine
(for example, bus detours or missing your bus)?
Are you able to recognize changes in your mental/emotional state?
Are you able to communicate needs?
Are you able to cross streets independently?
SECTION 3: COGNITIVE/VISUAL IMPAIRMENTS
Are you able to recognize destinations, bus stops, and/or landmarks?
Are you able to process spoken words and auditory information?
Are you able to recognize printed information?
Are you legally blind?
If this section is not applicable, please skip to Section 4.
If you answered "Otherwise Changing," please describe:
Do you have a visual impairment, if yes, please describe:
Page 7 of 10
Transfort/Dial-A-Ride Eligibility Application
3. If you use a wheelchair or scooter please answer the following:
□ YES □ NO
□ YES □ NO
□ YES □ NO
□ YES □ NO
Apt/Unit No.
Is it more than 30 inches wide?
Is it more than 48 inches wide?
Is the combined weight of the device and occupant more than 600
pounds?
□ Lift Equipped, please explain: ____________________________________
2. Do you require a lift-equipped vehicle, or are you able to travel in a sedan-style vehicle? Please
note, this is only for scheduling purposes as Dial-A-Ride utilizes different types of vehicles.
NOTE: Certification of the combined weight may be required and is the responsibility of the applicant.
□ Sedan, please explain: __________________________________________
SECTION 4: ADDITIONAL INFORMATION
The following are general questions to help Dial-A-Ride better serve its customers. Please answer all
applicable questions to the best of your ability.
□Power Wheelchair□Manual Wheelchair□Boarding Chair □Transfer Board
Relationship to Applicant
Address
City State Zip Code
If there is an additional party you would like your Eligibility Determination letter sent to, please fill out
the following information:
Last Name First Name
5. When using paratransit service, would you need to travel with a
PCA? A Personal Care Attendant (PCA) is a person traveling as
an aide who is designated or employed by a person with
disabilities to help meet personal needs and/or facilitate travel.
□Other (please explain): □Communication Aid
1. Which of the following mobility aids do you use when using transportation? (Please check all that ap
□Cane □Crutches
□White Cane □Portable Oxygen□Walker □Prosthesis
□Service Animal
□Power Scooter/Cart
Page 8 of 10
Transfort/Dial-A-Ride Eligibility Application
Preparer's Signature Date (mm/dd/yyyy)
First Name
Relationship to Applicant Day Phone (xxx)xxx-xxxx
The information provided on this form is private data and is used to determine ADA paratransit eligibility. The
ability to determine your eligibility is based on receiving all of the information requested on this form. All
medical or location information pertaining to application for, or users of, ADA paratransit service is private,
except the name of the applicant or user. Any other information cannot be released to anyone else, unless
the applicant or user authorizes the release in writing.
I certify that all the information on this application form is accurate. I understand that misinformation or
misrepresentation of facts will be cause for disqualification or rejection of my ADA eligibility. I also understand
that a professional who understands my health condition or disability may be contacted to clarify or obtain
additional information required to determine my eligibility or service needs. Information will be requested from
a professional only when the information provided on the application form does not clearly determine ADA
paratransit eligibility.
Applicant's Signature Date (mm/dd/yyyy)
SECTION 5: CERTIFICATION & SIGNATURE
The City of Fort Collins will make reasonable accommodations for access to City services, programs, and
activities and will make special communication arrangements for persons with disabilities. This includes
language access to all individuals who have a limited ability to speak, read, write, or understand English by
providing interpreters free of charge and translation of vital documents for persons who utilize the City's
services. Please call 970.221.6620 (V/TDD: Dial 711 for Relay Colorado) for assistance.
Last Name
If someone other than the applicant is preparing this form, please provide the following information
about the preparer:
Page 9 of 10
Transfort/Dial-A-Ride Eligibility Application
Apt/Unit No.
Applicant's Signature Date (mm/dd/yyyy)
Name Practice/Group Name (if applicable)
Name Practice/Group Name (if applicable)
Fax (xxx)xxx-xxxxPhone (xxx)xxx-xxxx
Phone (xxx)xxx-xxxx Fax (xxx)xxx-xxxx
Address
City State Zip Code
Applicant's Name (First and Last)Date of Birth (mm/dd/yyyy)
Street Address / City / State / Zip
I authorize the above-named professional(s) to release information to the City of Fort Collins Dial-A-Ride
program. I understand that this information will be used exclusively to determine my eligibility for ADA
paratransit services.
Professional 2 (if applicable):
Street Address / City / State / Zip
SECTION 6: AUTHORIZATION TO RELEASE MEDICAL INFORMATION
Professional 1:
In order to allow Transfort/Dial-A-Ride to evaluate your request for transportation under the Americans with
Disabilities Act of 1990, it is necessary to contact a health care provider or other professional that is familiar
with your disability.
Please note that in some cases, your primary care physician may not be the optimal source for verification of
your disability or health condition. If there is a specialist or other professional who is more familiar with your
particular disability or health condition (for example, Psychiatrist, Social Worker, Educator, Orientation and
Mobility Specialist, Neurologist, Physical Therapist, etc.) and has your recent medical history, please provide
that provider's contact information instead of your primary care physician.
Please provide the name, address and telephone number of your health care provider or other professional. If
there is more than one provider that you would like for us to contact, please list all applicable
names/addresses below:
Page 10 of 10
Transfort/Dial-A-Ride Eligibility Application
Transfort / Dial-A-Ride Phone: (970) 224-6002
6570 Portner Road Fax: (970) 207-7969
Fort Collins, Colorado 80525 Monday - Friday 8 a.m. to 5 p.m.
Contract Administrator, Transfort / Dial-A-Ride
250 N. Mason Street
Fort Collins, Colorado 80524
Who is Eligible for Paratransit Service?
There are no fees associated with the application process. Fees incurred such as transportation and mailing may be
reimbursed by sending a written request with a receipt or invoice to the address below. Fees will be verified and
reimbursed within 14 days of receipt of the request.
The Americans with Disabilities Act of 1990 (ADA) regulations provide that a person may be eligible for paratransit
services under one of the following three categories:
APPLICATION FOR ADA PARATRANSIT SERVICES
The primary public transit service provider in the City of Fort Collins is Transfort, the fixed route bus system. Persons
who are able to use Transfort fixed-route service are encouraged to do so. The ADA requires that transit agencies that
have fixed-route bus service provide complementary paratransit service to those persons with disabilities whose
disability prevents them from being able to use a fixed-route bus.
Persons who wish to qualify for the City of Fort Collins paratransit program must complete in full and return the
application form to Transfort / Dial-A-Ride. This includes completing and signing the attached "Authorization to
Release Medical Information" form, and return it with your application. When your application is received, we will send
a Health Care Provider (HCP) Verification form to the HCP that you identified on your application to verify your
disability or illness. It is important that you list the HCP who will be most familiar with your disability or illness.
Once the HCP form has been received by Dial-A-Ride, eligibility staff will begin to process your completed application.
Applications are not complete until the HCP form has been completed and received by Dial-A-Ride. Incomplete
applications may cause an interruption in the eligibility process. Dial-A-Ride will process your completed application
within 21 calendar days of receipt of the completed HCP form. If a decision is not made within this time, presumptive
eligibility will be granted until a decision can be made.
Eligibility for services is determined by information you provide and information we obtain from your health care
provider. Please contact Dial-A-Ride at (970) 224-6002 if you need this application in an alternative format or if you
have any other questions regarding the eligibility process, including eligibility information or renewals, application
status, or visitor status requests. Mail or fax completed applications to the address listed below:
Category 1 | The first category of eligibility includes those persons who are unable to use fully accessible fixed route
bus services. Included in this category is "any individual with a disability who is unable, as a result of a physical or
mental impairment (including a vision impairment), and without the assistance of another individual (except the
operator of a wheelchair lift or other boarding assistance device), to board, ride, or disembark from any vehicle on the
system which is readily accessible to, and useable by, individuals with disabilities" [Section 37.123(e) (1) of the ADA
regulations].
Page 1 of 10
Transfort/Dial-A-Ride Eligibility Application
Types of Eligibility Status
Recertification of Eligibility
Recertification of Service
Each Dial-A-Ride passenger must be recertified upon reaching their eligibility expiration date. Typically, eligibility
extends for three (3) years from certification. A passenger's ADA certification letter will indicate their paratransit
eligibility expiration date.
Based on individual needs, applicants may qualify for any of the following types of eligibility:
1 ǀ Unconditional - Full service for up to three (3) years.
2 ǀ Conditional - Any conditions applied to service is done so on an individual basis depending on the needs of the
passenger. Because conditions vary from one individual to another, they will be clearly explained on the eligibility
letter. Your eligibility specialist will be able to answer any questions you may have regarding your conditions.
3 ǀ Temporary - Temporary eligibility is provided to passengers who have a temporary disability/illness that prevents
them from using the Transfort bus system. Eligibility may be provided for the expected duration of the disability.
Temporary eligibility may be conditional or unconditional depending on the individual's needs. Any conditions, if
applicable, will be clearly explained on the eligibility letter.
4 ǀ Visitor Status - Visitors who have current ADA paratransit eligibility certification in any other jurisdiction in the
United States may use Dial-A-Ride for up to 21 calendar days a year by providing their ADA identification card or
certification letter. Visitors who do not have this certification but have a disability that prevents the access of fixed
route service may still be eligible as a visitor. An eligibility specialist will be able to assist you in qualifying as a visitor.
Category 2 | This category applies to an individual who would be able to use the fixed route bus system if it were
accessible (for example, if a low-floor or lift-equipped bus is not available, or if the bus stop or station is not
accessible).
Category 3 | "Any individual with a disability who has a specific impairment-related condition which prevents such
individual from traveling to a boarding location or from disembarking location on such system." [Section 37.123(e) (3) of
the ADA regulations]. Two important qualifiers to this category are included in the regulations. First, environmental
conditions and architectural barriers not under the control of the public entity do not, when considered alone, confer
eligibility. Second, inconvenience in using the fixed route bus system is not a basis for eligibility.
Please note that residency is not required in order to apply for service.
In the event that you are recertifying for service, a completed application is required in order to continue
receiving service. To avoid an interruption or discontinuation of paratransit service, please complete and
return the following application no later than ______________________.
Page 2 of 10
Transfort/Dial-A-Ride Eligibility Application
□New
M.I.
Gender
Work Phone (xxx)xxx-xxxx
Apt/Unit No.
Apt/Unit No.
M.I.
Work Phone (xxx)xxx-xxxx
Apt/Unit No.
□YES □NO
□YES □NO
□YES □NO
Email Address:
City State Zip Code
Mailing Address (if different from above)
Is this a new application or recertification?□Recertification
5. Who can act on your behalf with Dial-A-Ride (for example, schedule or cancel trips)?
2. Emergency Contact Information
Last Name First Name
Cell Phone (xxx)xxx-xxxx
1. Applicant Information
Address
Zip Code
Home Phone (xxx)xxx-xxxx
City State
SECTION 1: BASIC INFORMATION
Last Name First Name
3. Have you applied for Dial-A-Ride previously?
6. Are you currently a Colorado State University student, faculty, or staff?
Date of Birth (mm/dd/yyyy)
Relationship to Applicant
Home Phone (xxx)xxx-xxxx Cell Phone (xxx)xxx-xxxx
Address
City State Zip Code
4. Do you currently have, or have you had in the past, paratransit eligibility in
any jurisdictions?
Page 3 of 10
Transfort/Dial-A-Ride Eligibility Application
□Permanently □Intermittently □Temporarily □N/A
3. Do you use a mobility and/or communication aid?□YES □NO
□YES □NO
□Depending on the weather
5. A Personal Care Attendant (PCA) is a person traveling as an aide who is
designated or employed by a person with disabilities to help that person meet
his or her personal needs and/or facilitate travel. When using paratransit
service, would your health condition/disability require you to travel with a
PCA?
If you answered Temporarily, what is the expected date of recovery?
Recovery Date (mm/dd/yyyy)
□3/4 Mile (8 Blocks)□More than 3/4 Mile
Please estimate how many minutes this would take:_____________
□Other (please explain):□Communication Aid
4. Please indicate the furthest distance you are reasonably able to travel without the assistance of another person.
Please answer assuming you will be using your primary mobility device. Also, please assume you will be traveling on
level ground where there are no barriers or weather conditions affecting your mobility.
□Less than 200 feet □1/4 Mile (3 Blocks)□1/2 Mile (5 Blocks)
2. When does your health condition/disability require you to use paratransit service?
(check all that apply):
If you answered YES, please indicate which mobility and/or communication aid(s) you use (mark all that apply):
□Cane
□Crutches
□White Cane □Portable Oxygen
□Walker □Prosthesis
□Service Animal
□Power Scooter/Cart□Power Wheelchair□Manual Wheelchair
□Boarding Chair □Transfer Board
SECTION 2: GENERAL QUESTIONS
1. Do you have a health condition or disability that prevents you from independently using fixed-route bus service? If
so, please briefly explain.
6. Please explain any environmental (i.e. weather, temperature, physical barriers etc.) conditions or other
circumstances that prevent you from accessing and using a fixed-route bus:
Page 4 of 10
Transfort/Dial-A-Ride Eligibility Application
1. Do you currently use fixed-route bus service?□YES □NO
If YES, please indicate which routes you use (mark all that apply):□MAX □FLEX □HORN □2 □3 □5
□6 □7 □8 □9 □10 □11
□12 □14 □16 □18 □19 □31
□32 □33 □81 □92
How often do you use fixed-route service?___________________________________________
2. Have you ever had training to use the fixed-route buses?□YES □NO
□ YES □NO
□YES □NO
□YES □NO
□YES □NO
Would you be able to figure out what to do if you miss your bus?□YES □NO
□YES □NO
□YES □NO
□YES □NO
□YES □NO
4. If you currently use the fixed-route bus do you:
□Travel only to places that you are familiar with or have been trained to go?
□Use the City bus to travel independently throughout the City?
SECTION 3: FIXED ROUTE BUS
Please complete this section even if you are unable to use regular fixed-route bus service. This information will assist
us in determining how your disability/health condition affects your ability to use regular fixed-route bus service.
If yes, did you feel it was successful?
Who was the travel training performed by? ________________________________________
3. Please check "YES" or "NO" to the following questions:
Are you able to use a bus route schedule to determine the correct bus and
locate bus stops?
Are you able to identify the correct bus to take when there are multiple buses
servicing a stop or transit center?
Are you able to independently board/de-board a bus that is wheelchair
accessible?
Are you able to wait at a non ADA accessible bus stop WITH seating?
Are you able to wait at an ADA-accessible bus stop WITH seating?
Are you able to wait at an ADA-accessible bus stop WITHOUT seating?
Are you able to wait at a non ADA-accessible bus stop WITHOUT seating?
Page 5 of 10
Transfort/Dial-A-Ride Eligibility Application
□YES □NO
□YES □NO
□YES □NO
□YES □NO
□YES □NO
□YES □NO
□YES □NO
The following questions are about cognitive impairments, please check "YES" or "NO" to the following questions. If this
section is not applicable, please skip to Section 5.
SECTION 4: COGNITIVE IMPAIRMENTS
Are you able to communicate needs?
Are you able to cross streets independently?
Are you able to deal with unexpected situations or changes in routine (for
example, bus detours)?
Are you able to recognize changes in your mental/emotional state?
Are you able to recognize destinations, bus stops, and/or landmarks?
Are you able to process spoken words and auditory information?
Are you able to recognize printed information?
Page 6 of 10
Transfort/Dial-A-Ride Eligibility Application
□YES □NO
3. Is your visual impairment:□Degenerative □Stable □Otherwise Changing
□YES □NO
If yes:□Only on your own property?
□Only to places nearby? (for example, on your own block)
□Or to places further away? (go to next question)
5. If you are partially sighted, is your vision affected by any of the following? If yes, please explain.
□Bright Sunlight _________________________________________________
□Dimly lit or shaded places ________________________________________
□Darkness ____________________________________________________
SECTION 5: VISUAL IMPAIRMENTS
1. Please describe your visual impairment:
2. Are you legally blind?
The following questions are about visual impairments. If this section is not applicable, please skip to Section 6.
If you answered "Otherwise Changing," please describe:
4. Are you able to travel outdoors by yourself?
travel on quiet streets, or are you able to safely navigate busy intersections and/or traffic lights?
Page 7 of 10
Transfort/Dial-A-Ride Eligibility Application
2. If you use a wheelchair or scooter please answer the following:
□ YES □NO
□ YES □NO
□ YES □NO
□YES □NO
Apt/Unit No.
Relationship to Applicant
Address
City State Zip Code
If there is an additional party you would like your Eligibility Determination letter sent to, please fill out the following
information:
Last Name First Name
3. Would you like to find out more about our Travel Training program?
NOTE: Certification of the combined weight may be required and is the responsibility of the applicant.
□Sedan, please explain: __________________________________________
□Lift Equipped, please explain: ____________________________________
SECTION 6: ADDITIONAL INFORMATION
The following are general questions to help Dial-A-Ride better serve its customers. Please answer all applicable
questions to the best of your ability.
1. Are you able to travel in a sedan-style vehicle, or do you require a lift-equipped vehicle? Please note, this is only for
scheduling purposes as Dial-A-Ride utilizes different types of vehicles.
Transfort offers Travel Training to learn how to use the fixed route bus system. Training includes learning how to read
the maps and schedules, how to pay a fare, and how to make a transfer, among other things. Training can be one-on-
one or in a small group setting, onboard the bus or in a classroom.
Is it more than 30 inches wide?
Is it more than 48 inches wide?
Is the combined weight of the device and occupant more than 600 pounds?
Page 8 of 10
Transfort/Dial-A-Ride Eligibility Application
Last Name
If someone other than the applicant is preparing this form, please provide the following information about the
preparer:
Date (mm/dd/yyyy)
First Name
Relationship to Applicant Day Phone (xxx)xxx-xxxx
The information provided on this form is private data and is used to determine ADA paratransit eligibility. The ability to
determine your eligibility is based on receiving all of the information requested on this form. All medical or location
information pertaining to application for, or users of, ADA paratransit service is private, except the name of the
applicant or user. Any other information cannot be released to anyone else, unless the applicant or user authorizes the
release in writing.
I certify that all the information on this application form is accurate. I understand that misinformation or
misrepresentation of facts will be cause for disqualification or rejection of my ADA eligibility. I also understand that a
professional who understands my health condition or disability may be contacted to clarify or obtain additional
information required to determine my eligibility or service needs. Information will be requested from a professional
only when the information provided on the application form does not clearly determine ADA paratransit eligibility.
Applicant's Signature Date (mm/dd/yyyy)
SECTION 7: CERTIFICATION & SIGNATURE
Preparer's Signature
Page 9 of 10
Transfort/Dial-A-Ride Eligibility Application
Apt/Unit No.
Physician 1:
In order to allow Transfort/Dial-A-Ride to evaluate your request for transportation under the Americans with
Disabilities Act of 1990, it is necessary to contact a health care provider that is familiar with your disability.
Please note that in some cases, your primary care physician may not be the optimal source for verification of your
disability or health condition. If there is a specialist or other physician who is more familiar with your particular
disability or health condition (for example, Psychiatrist, Orientation and Mobility Specialist, Neurologist, Cardiologist,
etc.) and has your recent medical history, please provide that health care provider's contact information instead of
your primary care physician.
Please provide the name, address and telephone number of your health care provider. If there is more than one health
care provider that you would like for us to contact, please list all applicable names/addresses below:
SECTION 8: AUTHORIZATION TO RELEASE MEDICAL INFORMATION
Applicant's Signature Date (mm/dd/yyyy)
Doctor's Name Practice/Group Name (if applicable)
Doctor's Name Practice/Group Name (if applicable)
Fax (xxx)xxx-xxxxPhone (xxx)xxx-xxxx
Phone (xxx)xxx-xxxx Fax (xxx)xxx-xxxx
Address
City State Zip Code
Applicant's Name (First and Last)Date of Birth (mm/dd/yyyy)
Street Address / City / State / Zip
I authorize the above-named health care provider(s) to release information to the City of Fort Collins Dial-A-Ride
program. I understand that this information will be used exclusively to determine my eligibility for ADA paratransit
services.
Physician 2 (if applicable):
Street Address / City / State / Zip
Page 10 of 10
Can send an email with summary of thoughts instead of an official memo
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Board
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Commission Commission on Disability
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Advisory Board Citizen Review Board Water Board Senior Advisory Board
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Planning and
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Commission Women’s Commission Affordable Housing Board
Senior Advisory Board Natural Resources
Advisory Board Affordable Housing Board Parks and Recreation
Board Youth Advisory Board Natural Resources
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Women’s Commission Art in Public Places Board Cultural Resources Board Building Review Board Commission on Disability Parking Advisory Board
Zoning Board of Appeals Landmark Preservation
Commission
Landmark Preservation
Commission Energy Board Youth Advisory Board
Art in Public Places Board Transportation Board Planning and
Zoning Board Transportation Board
Citizen Review Board Zoning Board of Appeals Zoning Board of Appeals
Economic Advisory
Commission
Community Development
Block Grant Commission
Golf Board Energy Board
Parking Advisory Board Golf Board
Planning and
Zoning Board Water Board
Air Quality Advisory Board Senior Advisory Board
Cultural Resources Board
Land Conservation
Stewardship Board
Parks and
Recreation Board
Boards and Commissions Alignment to the Seven Key Outcome Areas
High Performing
Neighborhood Livability Culture and Recreation Economic Health Environmental Health Government Safe Community Transportation
■Largest Connection
■Secondary Connection
■Third Largest Connection
Updated: November 2014
City of Fort Collins ‘Outcomes’
Outcomes are the highest-level goals the City aspires to provide to our community. This
applies to residents and businesses, as well as those who are visi�ng. The progress
towards these Outcomes is achieved through the programs and services the City works
to provide.
Neighborhood Livability and Social Health
Fort Collins provides a high-quality built environment, supports
connected neighborhoods, seeks to advance equity and affordability,
and fosters the social health of the
community
Culture and Recrea�on
Fort Collins provides and maximizes access to diverse cultural and
recrea�onal ameni�es
Economic Health
Fort Collins promotes a healthy, sustainable economy reflec�ng
community values
Environmental Health
Fort Collins promotes, protects and enhances a healthy and
sustainable environment
Safe Community
Fort Collins provides a safe place to live, work, learn and play
Transporta�on and Mobility
Fort Collins provides a transporta�on system that moves people and
goods safely and efficiently while being accessible, reliable and
convenient.
High Performing Government
Fort Collins exemplifies an efficient, innova�ve, transparent, effec�ve
and collabora�ve city government