SMTD - Springfield Mass Transit District

Access Springfield - Welcome Aboard

ACCESS SPRINGFIELD

ADA ELIGIBILITY

Access Springfield provides curb-to-curb transportation for persons with disabilities who are unable to use the SMTD fixed-route bus service.

Individuals with disabilities must apply to become eligible to use the service. To become eligible, the individual must meet one of the three categories below.

1. An individual with disability who is unable, as the result of a physical or mental impairment, and without the assistance of another individual to board or disembark from any vehicle on the SMTD fixed-line system, which is readily accessible.

2. Persons who cannot use SMTD buses without lifts. (These persons are eligible for Access Springfield service if accessible, fixed-route vehicles are not availble on the route on which they need to travel or at the time they need to travel.)

3. Anyone with a disability who cannot travel to or from an SMTD bus stop.

Complete the application below and submit on-line OR you may print the application and mail to SMTD, 928 S. Ninth Street, Springfield, IL 62703.

Once you are approved, call 522-8594 to reserve a ride.

Springfield Mass Transit District
Application For Paratransit Eligibility

Federal law requires that the Springfield Mass Transit District provide Paratransit (hereafter referred to as Access Springfield) services to persons who cannot use available fixed route services. The information provided will allow us to make an appropriate evaluation of this request. Thank you for your cooperation in this matter. Please send to: SMTD, 928 South 9th Street, Springfield, IL 62703, (217)522-6087.

Applicant Name:

Address:

City:

State:

Zip:

Phone (Day):

Phone (Evening):

Paratransit service must be provided to the following three general groups of persons with disabilities:

An individual with a disability who is unable, as the result of a physical or mental impairment, and without the assistance of another individual to board or disembark from any vehicle on the SMTD fixed line system which is readily accessible.
Persons who cannot use SMTD busses without lifts (These persons are eligible for Paratransit service if accessible fixed route vehicles are not available on the route on which they need to travel or at the time they need to travel).
Anyone with a disability who cannot travel to/or from an SMTD bus stop.

Please answer the following questions. If you have questions or would like assistance, please contact SMTD or SCIL.

1.	What disability prevents you from using the SMTD fixed line buses?

Is your medical condition and/or disability temporary? (If your condition is temporary your application will be reviewed every six months)

Yes

Expected Duration?

Does your disability prevent you from getting to and from a bus stop?

	Yes		No
If Yes please explain...

How far can you walk without assistance?

Can you recognize your destination?

	Yes		No
If No, please explain...

Do you have difficulty in receiving verbal or written directions?

	Yes		No
If Yes please explain...

Is there a physical barrier that combines with your disability that prevents travel to and from the bus stop? (Example: Stairs, No Sidewalks, No curb cuts, Heat, Cold, Ice, Snow, etc.)

	Yes		No		Sometimes
If Yes/Sometimes please explain...

The following questions will help SMTD to understand your transportation needs.

Have you ever received SMTD bus training or mobility training?

Yes

Do you require assistance when traveling? If yes, check all that apply. (The only assistance the driver can provide is boarding, deboarding and securing passengers on the bus)

	Assistance from your door to the bus
	Assistance from the bus to the door
	Assistance boarding and deboarding
	Assistance with packages
	Assistance with mobility devices
	Other Assistance

An "A" will be added to your ADA number if you have checked items for which no service can be provided by the driver and you will be required to have someone help you.

NOTE:
The Access Springfield staff will monitor passengers´ abilities as they ride Access Springfield. If at anytime it is determined through these observations that the rider needs additional assistance to be able to safely use the service, the rider will be notified by Springfield Mass Transit District that an "A" is being added to their eligibility number. The rider must make arrangements for the assistance that is necessary or ridership will be denied. Access Springfield will not transport individuals who cannot be transported safely.

The rider may appeal this decision in writing to Linda Tisdale, who will not be involved in the initial decision. She may be reached at the Springfield Mass Transit District at 928 South Ninth Street, Springfield, Illinois, 62703.

OPTIONAL:

This section to be completed by person assisting applicant with form:

Name:

Title:

Address:

City:

State:

Zip:

Phone:

Access Springfield, paratransit and other special services

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