OFFICE USE ONLY

ID. No. _____________

Exp. Date ___________

Date Received in Office

___________________

April 1999

Return completed application in person to:

SunVan

100 First Street S.W., 2nd Fl.

Albuquerque, NM 87102

Phone (505) 243-RIDE (V/TTY)

SUNVAN CERTIFICATION FORM

The information obtained in this certification process will be used by the City of Albuquerque Transit Department for the provision of transportation services.

PART I

TO BE COMPETED BY APPLICANT (Please Print or Type)

Last Name First Name Mid. Initial

Street Address Apt. No.

City or Town State Zip

Mailing Address City State Zip

Home Phone Work Phone Social Security No. Date of Birth

Please answer all of the following questions:

1. Are you sometimes able to board and disembark without assistance from an ABQ RIDE Bus without a wheel chair lift? (ambulatory passengers)

Yes c No c If no, explain: _______________________________________________________

2. Are you able to board and disembark without assistance from a ABQ RIDE Bus with a wheelchair lift?

Yes c No c If no, explain: _______________________________________________________

3. Are you able to travel to the nearest bus stop?

Yes c No c If no, explain: ______________________________________________________

Location: ___________________________________________ How Far _________________________________

4. Do you currently use ABQ RIDE Bus service? Yes c No c

What routes? _________________________________________________________________________________

5. Are you able to handle money and transfers, and are you able to use railings and handles?

Yes c No c If no, explain: _______________________________________________________

6. Are you able to keep balance while seated on a moving bus? Yes c No c

7. Are you able to understand schedules? Yes c No c

Understand and follow directions? Yes c No c

Process information to ride ABQ RIDE bus? Yes c No c

8. If you can use a lift-equipped bus, are you presently unable to ride because:

c One or more routes you want to ride do not have lift-equipped buses?

c The lift cannot be operated at bus stops where you need to board?

c Your wheelchair cannot be accommodated on a transit vehicle?

c Other? ____________________________________________________________________________________

9. Are you prevented from traveling to or from a bus stop boarding location for one or more of the following reasons?

c Inability to negotiate hilly terrain

c Extreme sensitivity to climatic conditions

c Allergic/environmental sensitivities

c Hyper-fatigue, frailty

c Night blindness

c Inability to cross busy intersections

c Inability to climb three 10 inch steps

c Bus stop to far away

c Other reasons, please explain: _________________________________________________________________

10. Are you able to perform the following functions without supervision?

a) Find your way between familiar locations?

Yes c No c Yes, with training c

b) Signal the bus driver to get off at a familiar stop and get off the bus there?

Yes c No c Yes, with training c

c) At a bus stop served by more than one bus route, can you distinguish the correct bus to board and indicate your intention to board?

Yes c No c Yes, with training c

11. Are you able to perform the following functions without the assistance of another person?

c Travel 200 feet (the length of a city block)

c Travel ¼ mile

c What is the maximum distance you can travel to get to a bus stop.

12. Is your ability to get from place to place affected by

c Terrain, such as steep hills, no sidewalks, no crosswalks or other conditions.

c Rain, snow, ice.

c Extreme temperatures of heat or very cold, windy weather.

13. Are you able to wait outdoors for 10 minutes? Yes c No c Sometimes c

If no. please explain: _______________________________________________________________________

14. Do you have trouble standing for more than 15 minutes? Yes c No c Sometimes c

If yes, please explain: _______________________________________________________________________

15. Does your disability allow you to use the bus when you are feeling well, and on bad days, you can’t make it to the stop, or even get on the bus? Yes c No c Sometimes c

16. Are there sidewalks at your residence? Yes c No c

17. How would you describe the terrain where you live? (very steep hill, long gradual hill, flat, etc.) ______________

____________________________________________________________________________________________

18. Are you able to cross the street or a busy intersection by yourself? Yes c No c

19. Have you ever received mobility training for routes or destinations? Yes c No c

What did you learn? _________________________________________________________________________________________

_________________________________________________________________________________________

20. If travel training were available, would you be interested in participating?Yes c No c

21. List three of your most frequent destinations, and how you get there?

Frequency

Destination Street Address of travel How do you get there now?

_______________________ ___________________ _______________________________________________

22. Are there places you would like to go that you cannot get to now?

Frequency

Destination Street Address of travel Barrier

_______________________ ___________________ _______________________________________________

23. How did you find out about the Sun Van Service?__________________________________________________

____________________________________________________________________________________________

The questions in this section are designed to give us a better understanding of your opinion about certain aspects of accessible fixed route bus service. Please read each question carefully and circle the number that indicates whether you agree, disagree, or are not sure.

	Agree	Disagree	Not Sure
1. The bus system is too complicated for me to figure out.	1	2	3
2. I’ve heard good stories about ABQ RIDE bus service from other people.	1	2	3
3. I’m not at all interested in using ABQ RIDE service for my transportation.	1	2	3
4. I have to have a seat on the bus, but afraid I won’t get one.	1	2	3
5. Everyone on the bus will be inconvenienced since it takes me longer to board. People will get angry.	1	2	3
6. Riding the bus makes me more vulnerable to crime, and I’m afraid for my safety.	1	2	3
7. I think my neighborhood has good bus service?	1	2	3
8. I’m afraid I’ll get off at the wrong stop?	1	2	3
9. Arriving at my destination on time is not important to me.	1	2	3
10. Lower ABQ RIDE bus fares compared to SunVan are an incentive for me to ride the bus.	1	2	3
11. Taking my trips by bus would take me too long.	1	2	3
12. I need help with the tie downs and I don’t think the ABQ RIDE driver will help me.	1	2	3
13. I’d have to get up earlier in the morning to use the bus.	1	2	3
14. Lifts on the buses break down very often, I don’t think the service is reliable.	1	2	3
15. If the bus moves before I’m seated, I’m afraid I might fall.	1	2	3

PART II

IN CASE OF EMERGENCY NOTIFY:

(Please select someone who would NOT be riding with you)

Name Relationship

Home Phone Work Phone

Address City State Zip

I certify that the information provided in this application is accurate. I understand that false information may result in the

Denial or annulment of Sun van Service. I further understand that all information will be kept confidential, and only the

information required to provide services I request will be disclosed to those who perform those services.

Applicant’s Signature Date

Interviewer’s Signature Date

I understand my responsibilities and rights for SunVan Service and they are:

1. SunVan is public transportation and I will be sharing rides with other passengers…………….……..………… c

2. SunVan does not provide emergency service………………………………………………………….....….. c

3. I must show my SunVan I.D. Card and pay the fare each time I ride…… … ……………………….....…... c

4. Three ‘No Shows’ in 30 days could result in ridership suspension…… ……… …… ……… ………....….. c

5. SunVan has 15 minutes before and 15 minutes after scheduled pick up time to arrive……… ……….….…. c

6. SunVan will wait only 5 minutes from the time it arrives………………………....…………………….…… c

7. A maximum of 3 round trips may be scheduled per phone call…………………….....……………..….…. c

8. SunVan is curb-to-curb service ………………………………………………………...........………...… c

Screening Committee Review:

Reviewed by ___________________________ Date _________________ Decision ___________________________

Comments _______________________________________________________________________________________

_________________________________________________________________________________________________

If applicant has been assisted by someone else in completing this application, that person must complete the following:

Name ____________________________________________________________________________________________

Address __________________________________________________________________________________________

City/State/Zip Code _________________________________________________________________________________

Relationship to the applicant __________________________________________________________________________

Day Time Phone _______________________________________________

PART III

TO BE COMPLETED BY APPROPRIATE HEALTH CARE PROVIDER

(Please Print or Type)

Please Check One: c Physician c Licensed Health Care Provider c Licensed Rehab/Social Worker

Applicant’s Name __________________________________________________________________________________

Medical diagnosis of condition causing disability. _________________________________________________________

__________________________________________________________________________________________________

Is this condition prevent applicant from using fixed route services (regular bus service)?

__________________________________________________________________________________________________

If yes, describe in detail ______________________________________________________________________________

__________________________________________________________________________________________________

The following information will be used to ensure that an appropriate vehicle is sent to provide transportation and

That an accurate analysis of applicant’s trip requests can be made by the SunVan Service.

Does applicant use any of the following aids for mobility? (check all that apply)

c Cane c Power Chair c Communication Board

c White Cane c Large Power Chair c Service Animal

c Walker c Power Scooter (3-wheel) c Portable Oxygen Supply

c Crutches c Manual Chair c Personal Care Attendant

c Leg Braces c Picture Board/Alphabet Board c Other Type of Aid ___________

	Yes	No
Can applicant walk or wheel ¼ mile without the assistance of another person?