Certification Of Disability Form - Wayne County Transportation System printable pdf download

Certification of Disability Form

Reduced Fare Transportation Services

Rural Transportation for Persons with Disabilities (PwD) Program

The purpose of this form is to provide written, independent verification that the applicant named below has a disability according to the

definition in the Americans with Disabilities Act. This form is to be completed by a profession who is familiar with the applicant’s

disability. A professional is someone who has medical training, provides rehabilitative or therapeutic services, does cognitive

assessments, or provides independent living and counseling services to people with disabilities. The applicant has applied for

transportation services under the Rural Transportation for Persons with Disabilities (PwD) program, which is being administered by the

Pennsylvania Department of Transportation with services provided by the Wayne County Transportation System. If you have any

questions about the form, please call 570-253-4280.

Applicant Information (to be completed by applicant):

Last Name: _____________________________________

First Name: _______________________________ M.I.: _____________

Address (Street & No.): _________________________________________________________________________________________

City: ____________________________________________________

State: __________________

Zip Code: _______________

Telephone: Home: _______________________________

Work: _________________________

E-mail: _____________________

___________________________________________________________________________________________________________

Applicant signature or that of the person who completed this form

Date

Definition of Disability

Eligibility for this program is based on disability as defined by the Americans with Disability Act (ADA). According to

the ADA, "Disability means, with respect to an individual, a physical or mental impairment that substantially limits one

or more of the major life activities of such individual; a record of such an impairment; or being regarded as having

such an impairment". "...major life activities means functions such as caring for one's self, performing manual tasks,

walking, seeing, hearing, speaking, breathing, learning, and work."

Please answer the following questions (to be completed by the agency or person providing verification of eligibility information)

Is the applicant’s disability permanent?

____ Yes

____No

(A standard definition of a permanent disability is one that lasts for 12 months or longer.)

If not, how long is it expected to last? _____________________________________________________________________________

What is the nature of the applicant’s disability? Check those that apply.

Please check all mobility aids that apply.

______ Mobility disability (please see question to the right)

______ Manual wheelchair

_________ Crutches

______ Vision disability

______ Power Wheelchair

_________ Cane

______ Hearing disability

______ Motorized Scooter

_________ Walker

______ Cognitive disability

______ Mental disability

______ Other — Please specify: _____________________________

___________________________________________________________________________________________________________

Signature of Professional

Date

___________________________________________________________________________________________________________

Title

Name of Agency or Organization

___________________________________________________________________________________________________________

Address

Telephone

Please send completed form to:

Wayne County Transportation System

323 10

Street

Honesdale, PA 18431

Certification Of Disability Form - Wayne County Transportation System

Related Articles

Related forms

Related Categories