Kingston Access Services - New Passenger Application Form ... ApplicationV2.pdf · Kingston Access Services - Application Form - April 2015 Appeal Process: • Drivers may arrive

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.

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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:

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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


• 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.

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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:

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[ ] [ ] 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.

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[ ]

[ ]

[ ]

[ ] 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?

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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


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.

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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


[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ] 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


[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

- - - -

[ ] [ ]

[ ] [ ]

[ ] [ ]

[ ] 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

Documents

Kingston Access Services - New Passenger Application Form ... ApplicationV2.pdf · Kingston Access Services - Application Form - April 2015 Appeal Process: • Drivers may arrive