Kingston Access Services - New Passenger Application Form ... ApplicationV2.pdf · Kingston Access...
Transcript of Kingston Access Services - New Passenger Application Form ... ApplicationV2.pdf · Kingston Access...
Kingston Access Services - New Passenger Application Form - APRIL 2015
PASSENGER APPLICATION
FORM
Kingston Access Bus services are for residents of the City of Kingston who are unable to use
conventional fixed-route transit (provided in the City of Kingston by Kingston Transit) due to
physical disability as per the Integrated Regulations of the AODA. Those with cognitive
disabilities may be eligible if their cognitive disability severely impacts their physical ability to use
conventional transit facilities and vehicles (e.g.. physical ability to board a conventional bus).
Eligibility is considered on a case-by-case basis and is not based on a specific health condition,
but how a specific medical condition impacts mobility. Health care providers cannot guarantee
eligibility.
• unwillingness or reluctance to use conventional fixed-route services on the part of the applicant.
Some applicants may only be eligible for service during the winter months (November 15 to
March 31).
As you complete this form, please keep in mind:
You may be able to use Kingston Transit’s fixed-route service for your trips. All of Kingston
Transit’s fixed-routes use accessible low-floor vehicles with ramps to assist individuals with
disabilities. Courtesy seating is located at the front of each bus for those who have mobility
limitations (especially those using wheelchairs, scooters or walkers) and passengers with
disabilities.
The information obtained in this form will only be used by Kingston Access Services to assess the
applicant's eligibility. All information contained in this application will be kept confidential.
Kingston Access Services does not provide this information to any other organizations.
This form is for use by persons who wish to apply for Kingston Access Bus, which provides "door
to door" specialized transit within the City of Kingston. Kingston Access Bus is operated by
Kingston Access Services, a not-for-profit organization. It is not operated by the City of Kingston,
or Kingston Transit.
If you have any questions or need assistance to complete this form, please call Kingston Access
Services at 613-542-2512.
Who qualifies:
Visitors to the City of Kingston may also be eligible to use Kingston Access Bus services within the
City of Kingston limits.
Please note: Eligibility with Kingston Access Bus is not based on:
• age, income, loss of drivers license, or the availability of others to travel with the applicant on
conventional transit;
• conventional fixed-route services not being offered in the area in which the applicant resides;
Passengers whose medical conditions require specific transportation (i.e. extreme fragility
requiring transportation below regular speeds) need to contact a medical carrier for
transportation.
Page 1 of 12
Kingston Access Services - Application Form - April 2015
Before you can use Kingston Access Bus services you must:
1. Complete "Part A: Applicant Information" (pages 5-8): Contains questions about your medical
conditions and how they impact your ability to utilize conventional transit. This is to be
completed by the applicant, or a designate acting on their behalf.
2. Have your Healthcare Professional review Part A and complete "Part B: Healthcare
Professional Certification" (pages 9-12). Please note: Any fees charged by your Healthcare
Professional for completion of application form are the responsibility of the applicant.
Kingston Transit offers "travel training" on accessibility features and bus routes to those with
disabilities. Additionally a "Guide to KT Accessible Services" handbook is available. For further
information on the accessibility of Kingston Transit's fixed-route service please call the City of
Kingston's customer service centre at 613-546-0000 Monday-Friday from 8am to 5pm.
3. Return both Parts A & B to Kingston Access Services via one of the following methods:
Incomplete/illegible applications will not be processed will be returned to the applicant. Upon
receipt of Parts A & B of the application form you will be contacted within 2 weeks by Kingston
Access Services as to the status of your application. Ambulatory passengers (i.e. those who do
not use wheelchairs) may be required to attend a Functional Assessment at the Kingston Access
Services office. Free transportation to/from the Functional Assessment is available through
Kingston Access Services.
c) Conditional Eligibility – Applicant has a disability where environmental or physical barriers limit
their ability to use conventional transit services. For example winter weather conditions, thus the
passenger is eligible only during winter months.
b) Temporary Eligibility – Applicant has a disability that temporarily prevents them from using
conventional transit services (for example a broken leg). Applicant is eligible on a temporary
basis.
Passengers qualifying for Kingston Access Bus services will be categorized with one of the
following levels of eligibility:
Categories of eligibility:
a) Unconditional Eligibility - Applicant has a disability which prevents them from using
conventional transit services on a permanent basis.
b) Scan and e-mail to: [email protected]
751 Dalton Avenue
Kingston, Ontario K7M 8N6;
Kingston Access Services
c) Mail or deliver to: a) Fax: 613-549-6318
As you complete this form, please keep in mind continued:
How to apply for Kingston Access Bus:
Page 2 of 12
Kingston Access Services - Application Form - April 2015
Appeal Process:
• Drivers may arrive within a "window" of 5 minutes BEFORE or AFTER your scheduled pick-up
time. Passengers are to be ready for pick-up accordingly. To ensure other passengers are not
inconvenienced, drivers are not required to wait more than 5 minutes for passengers
provided their arrival time is within the "window". Most KAB vehicles have AVL technology which
confirm location, and arrival/departure times in the event there is a question of such.
Other information:
Information for Wheelchair/Scooter Users
• All wheelchairs/scooters MUST have functioning brakes, and be capable of having the "tie-
downs" secured to the frame.
• Kingston Access Bus is a "shared-ride" service. We in many instances will pick-up/drop-off
other passengers during your trip. We try to minimize your travel time, however you may be on
the bus for up to 60 minutes. If you have a specific appointment time at your destination, please
make us aware of this at the time of booking so we can factor this into your pick-up time.
• All passengers who use 3-wheel scooters MUST transfer to a regular seat during transit. The
passenger must be able to transfer with minimal assistance from the driver.
• The maximum size for a mobility device that can be accommodated is 76cm (30 inches) wide;
125cm (50 inches) long; and the maximum combined weight of mobility device and occupant is
363kg (800 pounds).
• All mobility devices must be in good working condition in order to be transported. It is the
responsibility of the passenger to ensure their mobility device is safe for transit.
Support Persons:
Passengers may have one support person travel for free on Kingston Access Bus. Applicants who
wish to have a support person travel for free must have their Healthcare Professional confirm this
in sections 6 & 7 of the Healthcare Professional Certification documents.
Kingston Access Bus is not an attendant care service. If you require a support person during
transportation this person must be provided by you. A support person is a person whose
presence is required to assist the passenger with communication, mobility, personal care, or
medical needs. Please note: Kingston Access Bus drivers cannot provide special medical
assistance to passengers (for example feeding tubes). Kingston Access Bus drivers cannot
provide assistance to passengers while vehicle is in transit. Ambulatory passengers with
dementia / Alzheimer's / behavioral issues should always travel with a support person.
Applications which are declined may be appealed. The appeal will be heard by the Kingston
Access Services Board of Directors, or a panel of members appointed by the Board for that
purpose. Written notice of appeal, to be valid, must be received within 21 days of being notified
of original application being declined. No subsequent applications may be filed until 6 months
after the date of the original decision or appeal decision, whichever is later, unless satisfactory
evidence of a material change in medical condition is provided with the new application.
Page 3 of 12
Kingston Access Services - Application Form - April 2015
• Once registered, passengers may book trips up to 14 days prior to the day of trip. For example
trips on January 24th can be made starting on January 10th. Same day service can be
accommodated provided there is remaining availability.
• Further information on Kingston Access Services policies can be obtained from our website
(www.kingston.org/kas), or by calling Kingston Access Services (613-542-2512).
• Kingston Access Services does not and is not permitted by law to prioritize trips based on
purpose. All trips are on a first-come, first-serve basis based on availability.
• Please provide as much notice as possible when you need to cancel a trip so that we may
endeavour to accommodate other passengers. Excessive cancellations with less than 24 hours
notice and/or failing to show for a scheduled bus may result in progressive actions being taken up
to and including loss of booking privileges.
• Kingston Access Bus has a NO SCENT policy on all vehicles. Please refrain from wearing
scented products while being transported.
• Registered passengers who are inactive (i.e. do not use the service) for 3 years may have their
registration cancelled and be required to reapply.
• It is the responsibility of the passenger to ensure that the laneways, driveways, ramps, etc. of
residences (including multi-residence units) are maintained in safe condition and clear of
snow/ice. Failure to do so may result in transportation being denied.
Other information continued:
• Passengers who use service animals must complete a "Service Animal Registration Form".
Contact Kingston Access Services to obtain a copy of the form. Pets are not permitted unless
being transported directly to/from a veterinary clinic.
• Verbal abuse, physical abuse, or unacceptable behaviours towards passengers or Kingston
Access Services employees will not be tolerated and may be grounds for temporary or
permanent cancellation of registration with Kingston Access Services.
• Service is provided to/from the vehicle and the exterior entrance of a destination. Drivers do
not enter or accompany passengers beyond the building entrance. Drivers are not required to
ring a buzzer or doorbell, nor search for you when not present at the exterior entrance.
• Personal items (i.e. luggage, parcels, groceries) are limited to those which the passenger,
support person, companions can handle without assistance from the driver and be safely secured
by the passenger. Drivers are not required to carry items onto the bus for passengers.
Page 4 of 12
Kingston Access Services - Application Form - April 2015
- -
- - - -
- - - -
[ ]
- -
Version:15-04
PART A:
APPLICANT INFORMATION
Work /Cell phone number
Home phone numberCity (if other than Kingston)
Last name of applicant First name of applicant
Phone number of emergency contact Alternate number of emergency contact
E-mail address
Date of birth (day/month/year)
Postal code E-mail address
Address of applicant Apt. #
EMERGENCY CONTACT INFORMATION Last name of emergency contact First name of emergency contact
Relationship to applicant
IF YOU ARE COMPLETING THIS FORM ON BEHALF OF APPLICANT, PLEASE COMPETE THE FOLLOWING:
Last name of person completing form First name of person completing form
Phone number of person completing form Relationship to applicant
TO BE COMPLETED BY THE APPLICANT OR A PERSON ACTING ON BEHALF OF THE APPLICANT
OFFICE USE ONLY
REGISTRATION NUMBER
OR Check if same as emergency contact:
Page 5 of 12
Kingston Access Services - Application Form - April 2015
[ ] [ ] If temporary, for how long:
[ ] [ ] [ ]
[ ] [ ] [ ]
[ ] [ ] [ ]
[ ] All the time [ ] Occasionally
[ ] Yes [ ] No [ ]
[ ] Yes at all times [ ] [ ] No
[ ] Yes [ ] No
[ ] Yes at all times [ ] Yes, but only if the ramp is deployed
[ ] [ ]
Yes, but not in winter conditions
No, not at any time Unsure/Have never tried
3a. Does Kingston Transit operate within 400 metres of your residence?Unsure
If not due to physical disability, this is as a result of:
If the answer to above is "no", is this due to your physical disability?
3c. Are you physically able to get on/off a conventional low-floor bus?
3b. Are you physically able to walk a distance of 175 metres (for example to a bus stop)?
1a. Please describe in detail the nature of your disability/disabilities/medical conditions.
Walker 4-wheel scooter Other:
2b.Do you use the mobility aids listed above:
1b. Is your disability/medical condition:Permanent Temporary
2a. Do you use any of the following mobility aids / devices?
Manual Wheelchair Oxygen 3-wheel scooter (Passenger must transfer to regular seat)
Power Wheelchair Cane / Crutches Service animal (Service animals must be registered)
The following questions are regarding your physical ability to use conventional transit
services, offered in the City of Kingston by Kingston Transit.
Page 6 of 12
Kingston Access Services - Application Form - April 2015
[ ]
[ ]
[ ]
[ ] Physical disability [ ] Cognitive disability
[ ] Behavioral challenges [ ] Memory Issues/Confusion
[ ] Medical condition (please specify):
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
4a. Do you require a support person to accompany you on the bus when you use Kingston
Access Bus services? Please note: It is the responsibility of the passenger to arrange a
support person. It is strongly recommended that those with cognitive disabilities (i.e.
dementia/Alzheimer's), behavioral challenges, or those who utilize medical equipment (i.e.
feeding tubes) travel with an attendant at all times. Support persons travel for free.
4e. The vehicle operator will be absent from the vehicle while escorting other passengers
to/from building entrances. Can you safely be left on the vehicle unattended without
attempting to disembark and leave, disrupt other passengers, etc.
Yes, I can be left on the vehicle unattended.
No, I cannot be left unattended.
Please note: It is mandatory that passengers who cannot be left alone provide an
emergency contact (see page 5).
Please answer the following questions to assist us in safely providing transportation to
and from your destination.
4b. If you require a support person at all times/occasionally, this is due to:
4d. Once at your destination can you safely be left unattended on your own without risk of
becoming disoriented or lost? Please note: Kingston Access Bus will provide assistance to
and from the building entrance. Drivers do not assist passengers inside of destinations.
I can be left safely on my own at my destination
No, I cannot be left unattended
Yes, I can independently identify my destination.
No, I cannot independently identify my destination.
Yes, I require a support person at all times. Note: In this case, service will only be
provided when a support person is travelling with you.
I occasionally require and will have a support person travelling with me.
No I do not require a support person
4c. Can you independently identify your destination?
Page 7 of 12
Kingston Access Services - Application Form - April 2015
5a. Does your residence have a ramp or lift to access the entrance?[ ] Yes [ ] No
5b. Does your residence have steps to access the entrance?[ ] [ ] No
[ ]
[ ]
[ ]
[ ]
[ ]
I certify that the information provided in this application is true and correct. I understand that
misinformation or misrepresentation of the facts will be cause for disqualification or rejection of my
eligibility. I also understand that additional information relating to my disability or health condition may
be required to determine eligibility. I hereby consent to Kingston Access Services contacting my
healthcare professional if additional information or clarification is required.
Signature of applicant or person completing on
behalf of applicantDate
APPLICANT SIGNATURE
6a. Kingston Access Bus occasionally utilizes taxi services for passengers who are
ambulatory (i.e. use walkers, canes, etc). Can you transfer in/out of a regular taxi (4-door
sedan style)? Yes, I can transfer in/out of a regular taxi
Yes, If so how many:
Please note: Kingston Access Services drivers will assist passengers in manual wheelchairs
up/down 1 step. If more assistance is required it is the responsibility of the passenger to
arrange such for the time of pick-up/drop-off.
7. Please add any other information or comments you believe will be helpful to us in
providing safe and efficient transportation for you.
No I cannot transfer in/out of a regular taxi
6b. Can you safely travel via taxi (i.e. identify destination,)?
Yes, I can safely travel via taxi.
Yes, but only if I am with a support person.
No I cannot safely be transported via taxi.
Page 8 of 12
Kingston Access Services - Application Form - April 2015
PART B: HEALTHCARE PROFESSIONAL CERTIFICATION Version 15-04
You are being asked by the applicant named in Part A of this application to provide information
regarding his/her disabilities and/or medical conditions to Kingston Access Services. The
information you provide will be used to evaluate the request and provide appropriate service.
Kingston Access Services operates Kingston Access Bus, which provides specialized transit to
residents of the City of Kingston. Applicants would be considered eligible if they are unable to use
conventional fixed-route transit (provided in the City of Kingston by Kingston Transit) due to
physical disability. Those with cognitive disabilities may be eligible if their cognitive disability
severely impacts their physical ability to use conventional transit facilities and vehicles (i.e. ability
to board a conventional bus).
Eligibility is considered on a case-by-case basis and is not based on a specific health condition.
Please note that eligibility is not based on: age, income, loss of drivers license, availability of
others to travel with the applicant on conventional transit, lack of conventional transit where the
applicant resides, or an unwillingness or reluctance to use conventional transit.
Kingston Access Services does offer "seasonal eligibility" for those whose physical mobility is
impaired during the winter months. Please note that applicants whose medical conditions require
specific transportation (i.e. extreme fragility requiring transportation below regular speeds) need
to contact a medical carrier for transportation.
Please complete this form in detail. Forms which are unclear, vague, or incomplete will be
returned to the applicant. Any charges for completing this form, or any additional information
required are the responsibility of the applicant. If you require further information please contact
our office.
Name of patient this form is being completed on behalf of:
1. Applicant's disabilities / medical conditions. Please provide information on severity of
disabilities/conditions where applicable.
Page 9 of 12
Kingston Access Services - Application Form - April 2015
2a. Does the applicant use any of the following mobility aids / devices?
[ ] [ ] Oxygen [ ]
[ ] Power Wheelchair [ ] Cane / Crutches [ ] Service animal
[ ] [ ] [ ]
2b.Does the applicant use the mobility aids listed above: [ ] All the time [ ]
[ ] [ ] Inability to stand for periods
[ ] Left-side weakness [ ] Right-side weakness
[ ] History of falls [ ] Other (pls. specify)
[ ] Yes at all times [ ] [ ] No
[ ] Yes [ ] No
[ ] Yes at all times [ ] Yes, but only if the ramp is deployed
[ ] [ ]No, not at any time Unsure
Manual Wheelchair 3-wheel scooter
Please answer the following questions based on the applicants physical ability to use
conventional transit services, offered in the City of Kingston by Kingston Transit.
4a. Is the applicant physically able to walk a distance of 175 metres (for example to a bus
stop)?
Yes, but not in winter conditions
If the answer to above is "no", is this due to physical disability?
3. Please provide information on how the applicants disabilities/medical conditions impact
their physical mobility.
Occasionally
Walker 4-wheel scooter Other:
2c. For ambulatory passengers: The applicant uses the mobility device due to:
Stability/balance concerns
If not due to physical disability, this is as a result of:
4b. Would the applicant be physically able to get on/off a conventional low-floor bus with
no steps?
Page 10 of 12
Kingston Access Services - Application Form - April 2015
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ] Physical disability [ ] Cognitive disability
[ ] Behavioral challenges [ ] Memory Issues/Confusion
[ ] Medical condition (please specify):
[ ]
[ ]
5c. Does the applicant require a support person to accompany them on the bus when using
Kingston Access Bus services? Please note: It is strongly recommended that those with
cognitive disabilities (i.e. dementia/Alzheimer's), behavioral challenges, or those who
utilize medical equipment (i.e. feeding tubes) travel with an attendant at all times. Support
persons travel for free.
5b. Can the applicant independently identify their destination?
Yes, they can independently identify their destination.
No, they cannot independently identify their destination.
Yes, a support person is required at all times when using the bus. Note: In this case,
service will only be provided when a support person is travelling with the applicant.
The applicant will occasionally require a support person travelling with them.
No the applicant does not require a support person on the bus with them on the bus.
5d. If the applicant requires a support person at all times/occasionally, this is due to:
5e. The vehicle operator will be absent from the vehicle while escorting other passengers
to/from building entrances. Can the applicant safely be left on the vehicle unattended
without attempting to disembark and leave, disrupt other passengers, etc.
Yes, the applicant can be left on the vehicle unattended.
Please answer the following questions to assist us in safely providing transportation to
and from the applicants destination.
5a. Once at their destination can the applicant safely be left unattended on their own
without risk of becoming disoriented or lost? Please note: Kingston Access Bus will provide
assistance to and from the building entrance. Drivers do not assist passengers inside of
destinations.
The applicant can be left safely on their own at their destination
No, the applicant cannot be left unattended
No, the applicant cannot be left unattended.
Page 11 of 12
Kingston Access Services - Application Form - April 2015
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
- - - -
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] Other (please specify):
Certified Rehabilitation SpecialistPhysiotherapist
Yes, the applicant can safely travel via taxi.
Yes, but only if accompanied by a support person.
No the applicant cannot safely be transported via taxi.
Professional Designation
Licensed Physician Registered Occupational Therapist
Registered Nurse Licensed Physical Therapist
Phone number of Healthcare professional Date (day/month/year)
7. If the applicant qualifies for specialized transit services, it is my professional opinion
that they will require the service: On a permanent basis
Temporarily
5f. Kingston Access Bus occasionally utilizes taxi services for passengers who are
ambulatory (i.e. use walkers, canes, etc). Can the applicant safely travel via taxi (i.e.
identify destination,)?
Est. Number of months needing service
Seasonally in winter conditions on a permanent basis
6. Please provide us any further information on the applicant which may assist us in
providing safe and efficient transit to the applicant or their medical conditions.
Last name of Healthcare professional
completing form
Signature of Healthcare Professional
Page 12 of 12