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60 APPENDIX A Survey Instrument TCRP Project J-07, Synthesis Topic SB-25 ADA Paratransit Assessment Centers Survey Study Objectives: This TCRP Synthesis study is examining facilities used by transit agencies to make determinations of ADA paratransit eligibility. In particular, it is examining facilities that are used for in-person interviews and functional assessments. This includes indoor facilities as well as outdoor routes and courses used for functional assessments. The study is gathering information about facility design, equipment and props used, the initial cost of creating the facilities, and the ongoing costs of operating the facilities. Your transit agency has been identified as one that uses in-person interviews and/or functional assessments to make ADA paratransit eligibility determinations. It would be appreciated if you could provide the information requested below. Once we have received this information, we will follow-up with you to be sure we understand your eligibility determination process and the facilities that you use. If some of the information requested below is not readily available, please provide what you can and we can gather remaining information as part of our follow-up call. Thank you for your assistance. GENERAL INFORMATION Transit Agency Name: Address: Contact Person: Title: Phone #: Fax #: Email: ADA PARATRANSIT ELIGIBILITY DETERMINATION PROCESS INFORMATION 1. For each of the following, please indicate if it is part of your ADA paratransit eligibility determination process. a. Paper application forms completed by applicants or others on their behalf Yes No If Yes, are application forms: Completed and sent in Completed and brought to interview appointments Completed at the time interviews are conducted Other: b. Verification of disability and/or functional abilities by professionals familiar with applicants Yes No If Yes, is information from professionals: Obtained by applicants and included as part of the application form Obtained on an âas neededâ basis by eligibility determination staff Not required, but can be submitted by applicants Required to be provided by applicants with certain disabilities Other:
61 c. In-person interviews Yes No If Yes, are interviews: Required for all applicants Conducted only for some applicants Other: d. Physical functional assessments Yes No If Yes, what types of physical functional assessments are used (check all that apply)? Tinetti Balance & Gait Test Indoor assessment along a designed route with simulated barriers Outdoor assessment along a designated route with various types of barriers Other: e. Cognitive functional assessments Yes No If Yes, what types of cognitive functional assessments are used (check all that apply)? Functional Assessment of Cognitive Transit Skills (FACTS) Mini Mental Status Exam (MMSE) Cognitive abilities are assessed along with physical abilities as applicants navigate the indoor/outdoor assessment route Other: f. Assessments of vision Yes No If Yes, what types of functional assessments are used to assess vision (check all that apply)? Assessment by an O&M specialist Vision is assessed along with physical and cognitive abilities as applicants navigate the indoor/outdoor assessment route Other: 2. Does your transit agency contract out for assistance with determinations of ADA paratransit eligibility? Yes No If Yes, please list the compan(ies) or organization(s): Transit Staff Contractor Staff Both Not Applicable Review of application forms Obtain information from professional Conduct interviews Conduct physical functional assessments Conduct cognitive functional assessments Conduct assessment of vision Make final eligibility determination If Yes, please indicate whether transit agency or contractor staff perform the following tasks:
62 ADA PARATRANSIT ELIGIBILITY DETERMINATION FACILITIES AND EQUIPMENT 3. How many locations/facilities are used for conducting interviews and/or functional assessments? One central location More than one location (indicate number of sites): ( ) 4. Which of the following statements best describes the facility(ies)? The eligibility facility(ies) are located within transit centers/facilities The eligibility facility(ies) are owned/leased by the transit agency but are separate from transit facilities The eligibility facility(ies) are located within the facilities of the company/organization we contract with for assistance with the process The eligibility facility(ies) are owned/leased by the company/organization we contract with, but are not co- located with other services provided by the contractor Other: 5. Please attach or scan and send a floor plan of the facility, or portion of the facility, that is used for ADA paratransit eligibility determinations. Note: If you use more than one facility, please select and provide a floor plan for the one facility that you feel is most adequate. 6. What space, equipment, or props are included within the facility (check all that apply)? Administrative offices (A) Waiting area for applicants (B) Restrooms (C) Interview rooms (D) Scale for weighing applicants using large mobility devices (E) Area for conducting indoor physical functional assessments (F) Measured course for assessing distance/endurance Mock-up of curb/curb-ramp Ramps to simulate hills/slopes Variety of surfaces to simulate travel over varied terrain Bus or bus mock-up to simulate boarding/disembarking Measured area to simulation street crossing Mock-up of traffic controls as part of street crossing Other: Separate area for conducting cognitive functional assessments, such as FACTS (G) Space for paper determination files (H) Other: (I) If possible, please label the facility floor plan using the letters above (A-I) to indicate the location of each of the above areas. If this is not easily possible, we will go over the facility layout as part of our telephone follow-up. 7. What is the total square footage of the facility, or portion of the facility, dedicated to ADA paratransit eligibility determinations? sq.-ft. If possible, include a scale on the floor plan, or provide one measurement that we can use to estimate size of the facility and functional areas. 8. Are any of the following services also located at the facility (check all that apply)? Travel training services Transportation resource center Other:
63 11. Who did the initial facility build-out? Transit agency Eligibility contractor Other: 12. In what year did you start using the current facility(ies)? 13. In the most recent fiscal year, what was the annual facility cost for the facility illustrated in the attached floor plan? Rent (or depreciation if transit owned facility) $ Utilities and maintenance costs $ Other: $ TOTAL $ 14. If you use multiple facilities, what was the annual facility cost for all of your facilities? Rent (or depreciation if transit owned facility) $ Utilities and maintenance costs $ Other: $ TOTAL $ 15. If an outdoor route is used for functional assessments, please attach or scan and send a map or sketch of the route. Note: If you have multiple facilities, just provide a map or sketch of the outdoor route associated with the facility shown in the attached floor plan. Map or sketch of outdoor route is attached or is being sent We do not use an outdoor route for functional assessments a. Which of the following are included along the outdoor route (check all that apply)? Measured intervals for assessing maximum travel distance (up to ft) Rest areas along the route (A) Curbs (B) Curb-ramps (C) Hills or slopes (D) Broken sidewalk pavement (E) Other varied surfaces (F) Uncontrolled street crossing (G) Controlled street crossing (H) Other: (I) If possible, please label the outdoor route map using the letters above (A-I) to indicate the location of each of the above features. If this is not easily possible, we will go over the route features as part of our telephone follow-up. b. Does the outdoor route include a trip on a bus or train, if appropriate? Yes, a trip on a bus is sometimes made Yes, a trip on a train is sometimes made No 9. What was the cost to modify and equip the facility illustrated in the attached floor plan when it was first established? $ 10. If you have multiple eligibility determination sites, what was the cost to modify and equip all of your facilities? $
64 ADA PARATRANSIT ELIGIBILITY DETERMINATION STATISTICS 16. Please provide as many of the following process statistics as possible: Average Annual Weekday Number of completed applications received Number of in-person interviews conducted Number of physical assessments conducted Number of cognitive assessments conducted Number of vision assessments conducted OR Number of combined assessments conducted 17. Please provide as many of the following outcome statistics as possible: Total determinations in most recent year Unconditionally Eligible Conditionally Eligible Temporary Not Eligible ***** THANK YOU ***** Please return this completed form and attachments to Russell Thatcher at: rhthatcher@transystems.com
