| 1. |
Do you live in an ALF or nursing home, retirement or boarding house? |
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A. Does this facility have a vehicle that can transport you? |
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| 2. |
Do you have relatives or friends residing in this area? |
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A. Could this person transport you if you asked or paid for gas? |
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| 3. |
Does anyone at your residence own and operate a vehicle? |
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A. Can this vehicle be used to transport you? |
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| 4. |
Are there any special conditions of your disability that we need to know? |
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Explain:
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| The following information is used to ensure that an appropriate vehicle is utilized to provide your transportation. |
| 1. |
Do you use any of the following mobility |
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| 2. |
Please be specific in order for us to better serve you. |
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A. |
Distance you can travel without assistance: |
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B. |
Can you climb 12" step without assistance? |
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C. |
Can you wait outside without support for 10 minutes? |
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D. |
Can you give your address and phone number upon request? |
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E. |
Can you recognize a destination or landmark? |
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F. |
Can you ask for and follow directions? |
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G. |
Can you handle unexpected situations or changes in your routine? |
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H. |
Can you safely & effectively travel through crowded or complex facilities without an escort? |
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Comments:
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Vet must show ID and/or VA appointment slip. Limit 22 passengers or 16 passengers with 3 wheelchairs. |
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*** Riders can be refused transportation due to conduct. *** |
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