Paratransit Functional Ability Assessment Form
Applicant Information
Full Name
Date of Birth
Address
Phone Number
Disability Information
Disability or Condition
Duration of Disability
Mobility Aid(s) Used
Functional Ability
Ability to Walk
Independently
With Assistance
Unable
Maximum Walking Distance (meters/feet)
Ability to Climb Stairs
Yes
No
With Assistance
Can Wait Outdoors (minutes)
Can Transfer to Vehicle Seat
Independently
With Assistance
Unable
Cognitive Ability
Able to Understand Travel Instructions
Yes
No
With Assistance
Behavioral Concerns (if any)
Health Care Professional Information
Name
Title/Profession
Phone
Signature
Date
Additional Information