PHYSICIAN CERTIFICATION (to be completed by licensed physician or physiatrist) Part 1 Please stamp name and address – Physician/Psychiatrist Physician/Psychiatrist Address Physician/Psychiatrist Phone Number Physician/Psychiatrist Fax Number Signature of Physician/Psychiatrist Date ELIGIBILITY CRITERIA Part 2 Is the impairment or disability temporary? Yes No If temporary, what is the estimated period of time? From to Date Date PHYSICAL DISABILITIES Part 3 These four questions must be answered completely – Complete this section if the applicant has physical disabilities or impairments: A physical impairment is defined by the or condition, cosmetic disfigurement, or anatomical loss affecting one or more of ADA as: “Any physiological disorder the following body systems: Neurological, musculoskeletal, special sense organs, respirator (including speech organs), cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic, skin, and endocrine.” 1. What is the specific disability or impairment: applicant’s 2. Describe the specific disability or impairment: applicant’s 3. Explain how the disability or impairment substantially limits one or more major life activities applicant’s (activities most people are able to do), and does the applicant use a mobility device: 4. What special facilities, special planning or design does the applicant use to as hubs utilize RTA’s buses, facilities (such or schedules) and services? In other words, what accommodations does the applicant require to independently use public transportation? Page 2 of 3
PHYSICIAN CERTIFICATION (to be completed by licensed physician or physiatrist) Part 1 – Please stamp name and address Physician/Psychiatrist Physician/Psychiatrist Address Physician/Psychiatrist Phone Number Physician/Psychiatrist Fax Number Signature of Physician/Psychiatrist Date ELIGIBILITY CRITERIA Part 2 Is the impairment or disability temporary? Yes No If temporary, what is the estimated period of time? From to Date Date PHYSICAL DISABILITIES Part 3 – These four questions must be answered completely Complete this section if the applicant has physical disabilities or impairments: A physical impairment is defined by the ADA as: “Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: Neurological, musculoskeletal, special sense organs, respirator (including speech organs), cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic, skin, and endocrine.” 1. What is the applicant’s specific disability or impairment: 2. Describe the applicant’s specific disability or impairment: 3. Explain how the applicant’s disability or impairment substantially limits one or more major life activities (activities most people are able to do), and does the applicant use a mobility device: 4. What special facilities, special planning or design does the applicant use to utilize RTA’s buses, facilities (such as hubs or schedules) and services? In other words, what accommodations does the applicant require to independently use public transportation? Page 2 of 3
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