APPLICATION INSTRUCTIONS

All applicants must submit a complete application which includes both forms
(1) The Certification Questionnaire Form
(2) The Professional Verification Form

STEP 1 COMPLETE THE CERTIFICATION QUESTIONNAIRE

The Certification Questionnaire should be filled out by CeRTifiCATion
the applicant or the applicant’s advocate. The form QuesTionnAiRe
Americans with Disabilities Act (ADA) | Paratransit Eligibility

must be filled out in its entirety. It should be signed by 1. See application Instructions
2. If you have additional questions call Metro Mobility
Customer Service at (651) 602-1111 voice, (651) 221-9886 TTY.
We do not
accePt
aPPlications

the applicant or the applicant’s guardian and anyone

PART 3 who ApplicAnt signAture
3. This form is incomplete if it is noT AccompAnied by compleTed
professionAl verificATion.
by fax

assisted the applicant in completing the application.

The information provided on this form is private data and is used to determine ADA paratransit eligibility. This application and future written information are available in large print. Does large print better
The ability to determine your eligibility is based on receiving all of the information requested on this form. suit your needs?
All medical or locational information pertaining to application for or users of ADA paratransit service is
private. Any other information cannot be released to anyone else, unless the applicant or user authorizes
the release in writing. If you are determined ADA paratransit eligible, information about your eligibility PART 1 ApplicAnt dAtA Please Print or tyPe
status will be entered into a database maintained by the Minnesota Department of Public Safety, Driver
Name: ______________________________________________________________________________________
and Vehicle Services Division. This information could be used by Drivers License Division of the Depart- First Middle Initial Last

ment of Public Safety to (1) Reexamine your driving ability or, (2) Demand that you surrender your license Street Address: ____________________________________________________ Apt.#: ____________________
if a severe disabling condition has developed since the current license was issued. City: ______________________________________________________________ Zip Code: ________________

STEP 2 COMPLETE THE PROFESSIONAL VERIFICATION FORM

Day Telephone: ( ) ________________________ Evening Telephone: ( ) ________________
I certify that all information on this application form is accurate. I understand that misinformation or
misrepresentation of facts will be cause for disqualification or rejection of my ADA eligibility. I also Email Address: _____________________________________________________
understand that additional information relating to my health condition or disability may be required to I prefer communication via email: ____Yes ____No
determine eligibility. This information may be obtained through an in-person assessment or by
Birth Date:______/______/______
requesting information from a professional who understands my health condition or disability. Additional
information will be required only when the information provided on the application form does not clearly Do you have a Minnesota state ID card or Minnesota driver’s license? Yes No
determine ADA paratransit eligibility. ID # ______________________________ License # ______________________ Expiration Year: __________

mailing Address (if different from above)

Applicant’s signature: _____________________________________________ Date:______/______/______
*If the applicant is not his/her own guardian, the following information about the guardian is required: Street Address: ____________________________________________________ Apt.#: __________________

The Professional Verification Form must be completed by one of the

Guardian’s Name: (please print) _______________________________________________________________________________
• Does the individual experience
DayAuditory
First

Phone: ( hallucinations
any of the following:
Middle Initial

) ______________________________________________________
Last
City: ______________________________________________________________ Zip Code: ______________

emergency contact person

Eligibility ApplicAtion
following professionals who are familiar with the applicant’s condition:
Visual hallucinations Delusions Disassociation
• Does this prevent the individual from being oriented to person, place, and time? ____Yes ____No
Guardian’s signature: _____________________________________________ Date:______/______/______
First

Day Telephone: (
profEssionAl VErificAtion
Name: _____________________________________________________________________________________
Middle Initial

) _______________________ EveningActTelephone: (
) _______________
Last

• Is the individual currently being treated for any of the following: Americans with Disabilities (ADA)
*If someone other than the applicant or the applicant’s guardian is preparing this form, please provide the following

• Physicians or Psychiatrists
Anxiety about theDepression
information preparer: Panic attacks Schizophrenia
1. Are you able to travel in an automobile? ____Yes ____No
Other: _____________________ 1. Complete and sign the “Authorization to Release Information”. We do not
Name: (please print) _________________________________________________________________________________________
• For anxiety panicFirst
attacks please indicate
Middle on
Initial average the frequency
Last and length of panic attacks. [Link]
you use a wheelchair
to your designatedorprofessional.
scooter: accept
applications
• Occupational Therapists
Day 3. Wait Is for
it more than 30 inches
the professional to return ____Yes
wide?this ____No
form to you.
PerPhone: ( ) ______________________________________________________
day________ Per week________ Per month________ Per year________
Is it back
Check more with
thanyour
48 inches long? ____Yes
professional ____No
if you don’t receive your information. by fax
Approx. duration: ________ 4. This Is form is incomplete
the combined weightif of
it is noT and
device ACComPAnIed
occupant more bythan 600 pounds? ____Yes ____No
ComPleTed
• What technique(s) and/or skills is the individual utilizing to assist in coping with the above issue(s)? CerTIFICATIon QueSTIonnAIre.
preparer’s signature:______________________________________________ Date:______/______/______

• Psychologists Visualization Relaxation techniques

Other:______________________
Positive self-talk Aroma therapy

• Are these techniques effective in reducing symptoms? ____Yes ____No

sEction A RELEASE
AuThORIzATION TO please print or type

• Physical Therapists
INfORMATION
• Is there a history of Electroconvulsive Therapy (ECT)? ____Yes ____No ____Unknown
(whEN COMPLETE SENd TO ThE PROfESSIONAL yOu NAMEd)
COGNITIVE/MENTAL IMPAIRMENTS

• Licensed Independent Social Workers (LISW, LICSW)

Please list IQ score and GAF score if known. IQ = ___________ GAF = ___________
Applicant’s Name: ____________________________________________________________________________
First

Birth Date:______/______/______
Middle Initial Last

• Recreational Therapists
• Please describe the functional limitations caused by this impairment? Applicant’s Address: ________________________________________________ Apt.#: ____________________
___________________________________________________________________________________________ City: ___________________________________________ State: _____________ Zip Code: ________________
___________________________________________________________________________________________ Applicant’s Telephone Number ( ) ______________________________

• Speech/Language Pathologists
• Is the individual’s judgment impaired? ____Yes ____No
I authorize the following professional to release to the MMSC specific information as requested. It is
• If yes, please describe to what extent or give an example. ______________________________________ my understanding that the information released will be used solely to determine my ADA paratransit
_________________________________________________________________________________________ eligibility. I understand that I may revoke this authorization at any time. Unless revoked, this form will

• Certified Orientation and Mobility Specialists

• Is the individual able to live independently? ____Yes ____No allow that professional listed below to release information described for six months after the date
appearing below.
Additional Comments: ____________________________________________________________________
___________________________________________________________________________________________

• Registered Nurses (RN)

Name of Professional: _______________________________________________ Title: _____________________
MMSC Staff will make the final determination of the applicant’s eligibility
Applicant’s Signature: ____________________________________________ Date: ______/______/______
Doctor/Health Care Professional Signature: _________________________________________________

• Doctors of Chiropractic (DC) PLEASE RETuRN fORM TO APPLICANT PleASe PrInT so that we may contact you if needed

Name of Professional: ______________________________________________ Date: ______/______/______

Guardian’s signature required if the applicant is not his/her own guardian,

Guardian’s Signature:_____________________________________________ Date: ______/______/______

Title: _______________________________________________________________________________________
Street Address: ______________________________________________________________________________

To complete the Professional Verification Form

City: _____________________________________ State: ________ Zip Code: _________________________
Telephone Number: ( ) ____________________________ Fax: ( ) _____________________

1. Complete and sign the Authorization to Release Information.

2. Send the Professional Verification Form to your designated professional.
3. Wait for your professional to return the Professional Verification Form to you. Check
back with your professional if you have not received the form back in a timely manner.

STEP 3 SUBMIT BOTH FORMS TOGETHER

Submit both the Certification Questionnaire and the Professional Verification Form
in the same envelope to
Metro Mobility Service Center
390 N. Robert Street
Saint Paul, MN 55101-1805

WE DO NOT ACCEPT APPLICATIONS BY FAX OR E-MAIL See additional info on back

STEP 4 IN-PERSON ASSESSMENT
Usually the forms provide Metro Mobility Staff with all of the information needed to make a
determination on eligibility. Sometimes however more information is needed. When this happens
an applicant may be asked to come in for an “in-person assessment.”

This assessment may include:

• A conversation about the applicant’s current mobility. The Metro Mobility
evaluator will talk with you about how you currently get around.
• A pretend bus trip on the computer. This standardized test is designed to measure
a person’s cognitive ability to use regular fixed-route transit. (Functional Assessment of
Cognitive Transit Skills or FACTS for short.)
• A walk outside or through the skyway. This will help determine things such as
physical ability to get to the regular fixed-route bus as well as memory and landmark
recognition.
• A standard walking and balance test. This standardized test measures a
person’s risk of falling. (Tinetti Gait and Balance Test.)

PLEASE NOTE THAT APPLICANTS WHO NEED TO COME IN FOR IN-PERSON

ASSESSMENTS WILL STILL HAVE THEIR APPLICATIONS PROCESSED WITHIN
21 CALENDAR DAYS.

COMMON ISSUES

In order to make a determination within 21 calendar days the Metro Mobility Service Center must
have a complete application. There are several things which may cause an application to be
incomplete. By double checking these things PRIOR to submitting your application you may avoid
delays in processing.

1. One of the forms is missing. Your application must contain both the Certification Questionnaire
and the Professional Verification. Please ensure both are submitted in the same envelope.

2. One of the forms is not signed. Both the Certification Questionnaire and the Professional
Verification must be signed. If either the applicant or the professional forgets to sign the form it is
considered incomplete.

3. The professional credentials are missing. Professionals must include their titles and credentials
when signing the Professional Verification.

Jane Doe X (Incomplete) Jane Doe M.D. (Complete) Jane Doe R.N. (Complete)

AN INCOMPLETE APPLICATION WILL BE RETURNED TO THE APPLICANT ONE (1) TIME. IF IT IS SUBMITTED A
SECOND TIME AND IS STILL INCOMPLETE IT WILL BE HELD FOR 60 DAYS BY THE METRO MOBILITY SERVICE
CENTER BEFOREIT IS DISCARDED.

APPLICATIONS MUST BE PROCESSED WITHIN 21 CALENDAR DAYS. IF YOUR PROPERLY COMPLETED AND
SUBMITTED APPLICATION IS NOT PROCESSED WITHIN 21 DAYS, YOU WILL BE GRANTED PRESUMPTIVE ELIGIBILITY
FOR METRO MOBILITY SERVICE UNTIL YOUR APPLICATION IS PROCESSED.

Questions? Please call 651-602-1111

 CERTIFICATION
QUESTIONNAIRE
Americans with Disabilities Act (ADA) | Paratransit Eligibility

1. See application Instructions WE DO NOT

2. If you have additional questions call Metro Mobility ACCEPT
Customer Service at (651) 602-1111 voice, (651) 221-9886 TTY. APPLICATIONS
3. This form is incomplete if it is NOT ACCOMPANIED BY COMPLETED BY FAX
PROFESSIONAL VERIFICATION.

This application and future written information are available in large print. Does large print better
suit your needs?

PART 1 APPLICANT DATA PLEASE PRINT OR TYPE

Name: _______________________________________________________________________________________
First Middle Initial Last

Street Address: _____________________________________________________ Apt.#:_____________________

City:_______________________________________________________________ Zip Code:_________________
Day Telephone: ( )_________________________ Evening Telephone: ( ) _________________
Email Address:______________________________________________________
I prefer communication via email: ____Yes ____No
Birth Date:______/______/______
Do you have a Minnesota state ID card or Minnesota driver’s license? Yes No
ID #_______________________________ License # _______________________ Expiration Year: ___________

Mailing Address (if different from above)

Street Address: _____________________________________________________ Apt.#: ___________________
City: _______________________________________________________________ Zip Code: _______________

Emergency Contact Person

Name: ______________________________________________________________________________________
First Middle Initial Last

Day Telephone: ( ) ________________________ Evening Telephone: ( ) ________________

1. Are you able to travel in an automobile? ____Yes ____No

2. If you use a wheelchair or scooter:

Is it more than 30 inches wide? ____Yes ____No
Is it more than 48 inches long? ____Yes ____No
Is the combined weight of device and occupant more than 600 pounds? ____Yes ____No
3. Which of the following assistive devices, if any, do you use? (Please check all that apply.)
Cane Manual Wheelchair Boarding Chair Prosthesis
White Cane Powered Wheelchair Service Animal Communication Aid
Walker Powered Scooter/ Portable Oxygen Other (please describe):
Crutches Cart Transfer Board
If you selected Wheelchair or Scooter, would you prefer/need to use the device while riding in
Metro Mobility Vehicles? ____Yes ____No ____Sometimes

4. Does your health condition/disability require you to use Metro Mobility service:
Seasonally (Nov. - Apr.)
Permanently Temporarily
If temporarily, for how long? Week(s) Month(s)

5. Does your health condition/disability change from day to day in ways that occasionally
disrupts your ability to use regular-route city bus service? ____Yes ____No
If yes, please explain:_______________________________________________________________________

6. When using Metro Mobility service, does your health condition/disability require you to
travel with someone to assist and/or supervise you? ____Yes ____No

PART 2 QUESTIONS ABOUT USING

REGULAR-ROUTE PUBLIC TRANSIT

Complete Part 2 even if you are unable to use regular-route city bus service. This information will assist
us in determining how your disability/health condition affects your ability to use regular-route city bus
service.

7. Do you now independently use regular-route city buses? ____Yes ____No ____Sometimes
If “Yes” or “Sometimes,” how many times? per week per month per year
Which of the following best describes how you use regular-route city buses?
To travel to and from one destination only
To travel to and from a few destinations
To travel to and from many different destinations

Explain what prevents you from independently using regular-route city bus.

8. Have you ever had training to use the regular-route city buses? ____Yes ____No
9. Using a mobility aid or on your own, how far are you able to travel without the assistance of
another person? 3 blocks 6 blocks
9 blocks or more less than 3 blocks

10. I can wait for a regular-route city bus (check all that apply):
Only if there is a bench or shelter
Up to 15 minutes More than 15 minutes

11. Please check all the categories below as they relate to your ability to use regular-route
city buses:
I am: Yes No Sometimes
A. Able to tolerate very hot or very cold weather....................................
B. Able to recognize destinations, bus stops, or landmarks...................
C. Able to tolerate air pollution (smog, fumes, perfume).........................
D. Free from night blindness...................................................................
E. Able to recognize printed information.................................................
F. Able to hear and process spoken words or auditory information......
G. Able to communicate needs...............................................................
H. Able to follow directions......................................................................
I. Able to deal with unexpected situations or changes in routine
(example: bus detours)....................................................................
J. Able to safely and effectively travel through crowded and/or
complex facilities.............................................................................
K. Able to recognize changes in terrain...................................................
L. Able to travel independently along sidewalks and other
pedestrian ways...............................................................................
M. Able to cross streets independently....................................................
N. Able to find the correct bus stop........................................................
O. Able to identify the correct bus...........................................................
P. Able to get on and off a bus using the lift if necessary.......................
Q. Able to deposit fare into the fare box or show bus pass....................
R. Able to get to a seat/wheelchair position and remain seated
during a bus trip...............................................................................
S. Familiar with what to do if I miss my bus............................................

If you checked “No” or “Sometimes” to any of the items in question 11, please explain:

More Space Provided On The Next Page

PART 3 APPLICANT SIGNATURE
The information provided on this form is private data and is used to determine ADA paratransit eligibility.
The ability to determine your eligibility is based on receiving all of the information requested on this
form. All medical, visual or locational information pertaining to application for or users of ADA paratransit
service is private. No information related to Metro Mobility can be released to anyone else, unless the
applicant or user authorizes the release in writing. If you are determined ADA paratransit eligible,
information about your eligibility status will be entered into a database maintained by the Minnesota
Department of Public Safety, Driver and Vehicle Services Division. This information could be used by
Drivers License Division of the Department of Public Safety to (1) Reexamine your driving ability or, (2)
Demand that you surrender your license if a severe disabling condition has developed since the current
license was issued.

I certify that all information on this application form is accurate. I understand that misinformation or
misrepresentation of facts will be cause for disqualification or rejection of my ADA eligibility. I also
understand that additional information relating to my health condition or disability may be required to
determine eligibility. This information may be obtained through an in-person assessment or by
requesting information from a professional who understands my health condition or disability. Additional
information will be required only when the information provided on the application form does not clearly
determine ADA paratransit eligibility.

Applicant’s Signature:______________________________________________ Date:______/______/______

*If the applicant is not his/her own guardian, the following information about the guardian is required:

Guardian’s Name: (please print)________________________________________________________________________________

First Middle Initial Last

Day Phone: ( )_______________________________________________________

Guardian’s Signature:______________________________________________ Date:______/______/______

*If someone other than the applicant or the applicant’s guardian is preparing this form, please provide the following
information about the preparer:

Name: (please print)__________________________________________________________________________________________

First Middle Initial Last

Day Phone: ( )_______________________________________________________

Preparer’s Signature:______________________________________________ Date:______/______/______

 ELIGIBILITY APPLICATION
PROFESSIONAL VERIFICATION
Americans with Disabilities Act (ADA)

1. Complete and sign the “Authorization to Release Information”. WE DO NOT

2. Send to your designated professional. ACCEPT
3. Wait for the professional to return this form to you. APPLICATIONS
Check back with your professional if you don’t receive your information. BY FAX
4. This form is incomplete if it is NOT ACCOMPANIED BY COMPLETED
CERTIFICATION QUESTIONNAIRE.

SECTION A AUTHORIZATION TO
RELEASE INFORMATION PLEASE PRINT OR TYPE

(WHEN COMPLETE SEND TO THE PROFESSIONAL YOU NAMED)

Applicant’s Name: __First___________________________________________________________________________

Middle Initial Last

Birth Date:______/______/______
Applicant’s Address:_________________________________________________ Apt.#:_____________________
City:_ ___________________________________________ State:______________ Zip Code:_________________
Applicant’s Telephone Number ( )_______________________________

I authorize the following professional to release to the MMSC specific information as requested. It is
my understanding that the information released will be used solely to determine my ADA paratransit
eligibility. I understand that I may revoke this authorization at any time. Unless revoked, this form will
allow that professional listed below to release information described for six months after the date
appearing below.

Name of Professional:________________________________________________ Title:______________________

Applicant’s Signature:_____________________________________________ Date: ______/______/______

Guardian’s signature required if the applicant is not his/her own guardian,

Guardian’s Signature:______________________________________________ Date: ______/______/______

SECTION B METRO MOBILITY PROFESSIONAL VERIFICATION FORM
Dear Health Care Professional:
You are being asked to provide information regarding this individual’s disability. The Federal Law is very
specific about ADA para-transit eligibility. The law restricts eligibility to individuals who,
1. as a result of their disability, cannot board, ride, or disembark from a regular fixed route bus or
light rail car or
2. have a specific impairment-related condition which prevents them from getting to or from a bus
stop.
PLEASE NOTE: This does not include persons who find it difficult or uncomfortable to get to and
from bus stops. In providing information you should consider only the presence of a disability or health condition
and not the applicant’s age or economic status. Metro Mobility staff makes the final determination on eligibility status.

THIS SECTION MUST BE FILLED OUT FOR ALL APPLICANTS

GENERAL INFORMATION
• Describe the diagnosed disability you are currently treating this individual for:_______________________
____________________________________________________________________________________________
• Describe any other health conditions or disabilities with which this individual is diagnosed:___________
____________________________________________________________________________________________
• Date of onset ____/____/____
• Date of last visit ____/____/____
• How long have you worked with the individual? Since ____/____/____
• Is disability temporary ________ or permanent ________ ?
If permanent is disability progressive? ____Yes ____No
If temporary please give best estimate of rate of recovery. ____________________________________
• Is therapy part of treatment? ____Yes ____No If yes, give brief description________________________
____________________________________________________________________________________________
• Do temperature extremes affect the individual?
(Ex. Heat index of more than 85 degrees or wind chill less than 10 degrees) ____Yes ____No
If yes, how so?__________________________________________________________________________
• Please list all medications. _____________________________ ____________________________
_____________________________ ____________________________
_____________________________ ____________________________
• Is this individual compliant with taking medications? ____Yes ____No
• Does the individual currently uses regular route public transportation? ____Yes ____No ____Not Sure
• Is the individual’s judgment impaired ____Yes ____No
• Is behavioral inhibition impaired? ____Yes ____No
• Can the individual walk? ____Yes ____No
• Does the individual use a mobility aid? ____Yes ____No Please list ______________________________
____________________________________________________________________________________________
• How long has individual been using the device(s)?_______________________________________________
____________________________________________________________________________________________
• How far can the individual travel without the assistance of another person?
3 blocks 6 blocks 9 blocks or more less than 3 blocks
• With treatment/therapy will this distance increase? ____Yes ____No
• Please indicate the expected distance after treatment/therapy:
3 blocks 6 blocks 9 blocks or more less than 3 blocks
• Give best estimate of length of time required to achieve this improvement. _________________________
____________________________________________________________________________________________

PLEASE COMPLETE ONLY THOSE SECTIONS THAT APPLY TO THIS INDIVIDUAL

NEUROLOGICAL IMPAIRMENT/HEAD INJURY
• Does the individual experience seizures? ____Yes ____No Date of last seizure ______/______/______
• Please give no. of seizures ________ and frequency _____________________________________________
• What type(s) of seizures does patient experience________________________________________________
• Does individual experience auras? ____Yes ____No
• Is the individual’s judgment impaired? ____Yes ____No
• Is behavioral inhibition impaired? ____Yes ____No
• Does judgment and inhibition impairment prevent the individual from independently
traveling outside the home or immediate environment? ____Yes ____No
• When traveling independently does the individual have the ability to: (check all that apply)
Get help if lost Recognize & avoid danger Cross streets safely
Follow written directions Communicate needs Process information
Understand and follow schedule to get places on time

• Is there history of Brain Injury ____Yes ____No. Date of injury______/______/______

VISUAL IMPAIRMENT
• Please provide visual acuity measurements and visual field readings for both eyes.
OS: __________________________ OD: ________________________________
• Does the individual require any accommodations, adaptations, low vision aids, etc? Please list:
____________________________________________________________________________________________
____________________________________________________________________________________________
• How does the individual’s visual impairment affect their ability to move about in the environment?
____________________________________________________________________________________________
____________________________________________________________________________________________
• Has the individual received any orientation & mobility (O&M) training? ____Yes ____No

Questions? Please call 651-602-1111

 COGNITIVE/MENTAL IMPAIRMENTS
• Does the individual experience any of the following:
Auditory hallucinations Visual hallucinations Delusions Disassociation
• Does this prevent the individual from being oriented to person, place, and time? ____Yes ____No
• Is the individual currently being treated for any of the following:
Anxiety Depression Panic attacks Schizophrenia
Other: _____________________
• For anxiety panic attacks please indicate on average the frequency and length of panic attacks.
Per day________ Per week________ Per month________ Per year________
Approx. duration: ________
• What technique(s) and/or skills is the individual utilizing to assist in coping with the above issue(s)?
Visualization Relaxation techniques Positive self-talk Aroma therapy
Other:______________________
• Are these techniques effective in reducing symptoms? ____Yes ____No
• Is there a history of Electroconvulsive Therapy (ECT)? ____Yes ____No ____Unknown

Please list IQ score and GAF score if known. IQ = ___________ GAF = ___________

• Please describe the functional limitations caused by this impairment?

___________________________________________________________________________________________
___________________________________________________________________________________________
• Is the individual’s judgment impaired? ____Yes ____No
• If yes, please describe to what extent or give an example._______________________________________
__________________________________________________________________________________________
• Is the individual able to live independently? ____Yes ____No
Additional Comments:_____________________________________________________________________
___________________________________________________________________________________________

PLEASE RETURN FORM TO APPLICANT PLEASE PRINT so that we may contact you if needed

Name of Professional: ______________________________________________ Date: ______/______/______

Title:________________________________________________________________________________________
Street Address:_______________________________________________________________________________
City: _____________________________________ State: ________ Zip Code:__________________________
Telephone Number: ( ) ____________________________ Fax: ( )_ _____________________

Doctor/Health Care Professional Signature: _______________________________________________

*Form must be signed with credentials to be valid.