December 22, 2015

TO ALL PROSPECTIVE PROPONENTS

SUBJECT: ADDENDUM NUMBER 2

REQUEST FOR PROPOSALS NUMBER P36410

marta 2424 Piedmont Road, NE Atlanta, GA 30324-3330 404-848-5000

ELIGIBILITY ASSESSMENT SERVICES FOR MARTA's MOBILITY (PARATRANSIT)

OPERATION

Transmitted herewith is Addendum Number 2 to the subject Request for Proposals. The Request

for Proposals (RFP) is hereby modified as follows:

1. Revisions to existing text are identified by a vertical line in the right margin of the line in

which a revision occurs.

2. The pages replaced by this Addendum are identified by a number "A-2" in the top right

corner of the replaced pages.

DOCUMENT

Table of Contents

Part 1, Section 10 (g)

Part 2, Section 2(d)(iii)

Part 2, Section 2(i)(ii)(B)

Form 3 - Price Proposal

REPLACE PAGES

2 8

16 18

Exhibit A (SCOPE OF WORK) 54-57

Attachment A (Excel Workbook)

Attachment B (Sample Eligibility Assessment Documents)

DELETE EXISTING PAGES

2

8 16 18 26 54-57

3. Page 26, Price Proposal Form is being deleted and replaced with Attachment A, which

will also be uploaded to MARTA's website as a downloadable form.

METROPOLITAN ATLANTA RAPID TRANSIT AUTHORITY

~~ ~ iSaDl~h race Director, Contracts, Procurement and Materials

cc : MARTA's Website

Contract File

METROPOLITAN ATLANTA RAPID TRANSIT AUTHORITY www.itsmarta .com

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PART 4: FORM OF CONTRACT

1. Contract 2. Exhibit A: Statement of Work/Scope of Services 3. Exhibit B: Special Terms and Conditions 4. Exhibit C: Price Proposal 5. Exhibit D: Insurance and Bonding Requirements 6. Appendix A: Office of Diversity and Inclusion Requirements 7. Appendix B: Illegal Immigration Reform and Enforcement Act Affidavits 8. Attachment B (Sample Eligibility Assessment Documents) 9. Attachment A: Excel Workbook 10. Attachment B: Sample Eligibility Assessment Documents

f.

g.

h.

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Form 6 - Proponent's Qualification and Business References. Each Proponent is requested to furnish with their proposal the information called for by the form. If the form is omitted or if the information furnished is incomplete or inadequate, the Authority may require that additional information be submitted after the proposal deadline and before an award is made.

Form 7 - Client List. Each Proponent is requested to furnish with their proposal the information I called for by the form. The maximum required is five (5) clients.

Appendix A: Office of Diversity and Inclusion Requirements. MARTA's Office of Diversity and Inclusion ("DNI") program(s) applicable to this procurement and any Contract that may be awarded pursuant to this procurement are set forth in Appendix A attached hereto. Each Proponent must furnish the information requested by Appendix A with their proposal.

11. Ownership of Proposals: Each proposal submitted to MARTA will become the property of MARTA, without compensation to a Proponent, for MARTA's use, in MARTA's sole discretion.

12. Proposal Evaluation, Award and Multiple Awards:

a. Upon receipt and review of the Proposals, MARTA shall determine which Proponents, if any, are responsive and responsible. MARTA will notify each Proponent in writing of MARTA's determination. After the Proposal Deadline, MARTA's Source Evaluation Committee ("SEC") will evaluate each responsive proposal in accordance with the evaluation criteria described in this RFP. If MARTA elects to award this RFP, MARTA will award the same to the most responsive and responsible Proponent that submits a proposal that is in the best interest of MARTA to accept. Proponents may be required to make an oral presentation to the SEC at any stage of the selection and evaluation process.

b. The selection of the successful Proponent(s), if any, will be based on the following criteria, which are listed in descending order of importance:

(i) Qualifications and Experience; (ii) Methodology / Provision of Services; (iii) Cost to MARTA; (iv) Understanding of Requirements; and (v) An evaluation of the response to information requested in Appendix A regarding Equal

Employment Opportunity and Disadvantaged Business Enterprises.

c. MARTA anticipates that it will award a Contract to a single successful Proponent, if any.

13. Submission of Proposals:

a. Proposals must be submitted according to the requirements of this RFP. All blank spaces must be typed or hand written in blue or black ink. All dollar amounts must be typed or hand written BOTH in word and numeric forms (e.g., One Dollar and No Cents ($1.00)). Proponents are advised that the written figures will prevail over the numerical figures in the event of a discrepancy between the

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authorizing the Proponent to transact business in the State of Georgia prior to award.

(e) Response to all Requirements: The Proponent's response to all requirements must include, but is not limited to responding to all of the information contained in the Scope of Work. All responses must be in the same order as identified in the Scope of Work (See Exhibit A).

(f) Organizational Structure and Key Personnel: The Proponent must provide (a) an organizational chart of the Proponent's management structure and (b) corresponding resumes for each of the individuals listed on the organizational chart provided. The organizational structure and resumes must clearly identify the Proponent's management team.

(i) Legal form of the Proponent and the state in which it is domiciled. In the case where the Proponent is a partnership, joint venture or affiliation of two or more firms, please provide information for all participants and the nature of the relationship. This should include organizational documents and a brief description of the rights and obligations of the parties.

(ii) Resumes must include at least the following information:

a. Name and Title; b. Professional Background; c. Education; and d. Current and Past Employment.

(iii) The Proponent must also include a statement that clearly identifies the level of authority vested to each individual within Proponent's management structure to make decisions on behalf of the Proponent.

(iv) The Proponent should include the name, address, telephone and fax number for the contact person authorized to communicate and negotiate on behalf of the Proponent.

(v) List any outstanding disputes or business relationships between the Proponent and the following entities, if any:

a. MARTA; b. The United States Department of Transportation; c. Federal Transit Administration; d. Georgia Department of Transportation; e. City of Atlanta; f. County of Clayton; g. County of Cobb; h. County of DeKalb; i. County of Fulton; and/or j. County of Gwinnett.

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(ii) The names and phone numbers of references for the following:

(A) Two commercial banks; and (IJ} T',I,'9 instit~ti9nal partners. (8) Non-banking financial and/or surety institutions.

(iii) Terms and conditions of any significant contingent liabilities, such as guaranteed loans or other obligations which could affect the ability of Proponent to obtain financing for this project.

(iv) ANY FINANCIAL STATEMENTS THAT PROPONENT DEEMS TO BE CONFIDENTIAL SHOULD BE MARKED AS PROPRIETARY. FAILURE TO PROVIDE THIS INFORMATION MAY RESULT IN PROPONENT BEING DEEMED NON-RESPONSIVE.

NOTE: If the Proponent is a partnership, joint venture or newly formed entity (e.g., limited liability company or corporation), the minimum requirements set forth throughout the RFP must be satisfied by the entity or individual(s) that own and control a majority equity interest (i.e., over 50%) of the partnership, joint venture or newly formed entity.

3. Price Proposal. Each Proponent is required to fully complete the Price Proposal Form (Form 3) attached to this RFP.

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(d) Certification Process

• Ensure integration of travel training program in assessment process (identify and refer possible candidates)

• Enter all certification documentation and decisions in the Trapeze database

• Ensure quality control for eligibility decisions, including random review of eligibility files and observation of

assessments

• Receive determinations from contractor and communicate determinations to applicants within 21 day

requirement

• Transmit certification decisions to paratransit provider daily- imports into Trapeze certification CERT module (if

in place)

• Write/mail certification letters to applicants evaluated by contractor

• Conduct mail-in recertification process based on those applicants deemed eligible for "auto-renewal"

• Perform and log customer reminders for recertification (via Trapeze CERT module, if in place)

• MARTA has the right to reverse any eligibility determinations of the Contractor at MARTA's sole discretion

(e) Appeals process

• Recruit members of the appeals panel

• Establish schedule of panel meetings

• Provide training of panel members

• Coordinate and facilitate appeals hearings

• Represent MARTA at all appeals hearings

• Send final determinations to appellant after hearings

10. Contractor Responsibilities: The services shall include, but are not limited to each of the following:

(a) Receive completed applications and appointment schedules from MARTA Eligibility staff. Proactively resolve scheduling conflicts as needed.

(b) Interview each applicant/current registrant, as part of the interview process; identify applicants for whom a functional assessment is appropriate in order to make an eligibility determination. If needed, perform in-person functional evaluations of applicants' ability to use MARTA bus and rail services directly after the interview. Assessments can include one or more of the following depending on the applicant's most limiting condition: Physical; Tinetti (or other gait/balance test); Functional Assessment of Cognitive Transit Skills (FACTS); Mini Mental State Exam (MMSE). See Section 11 below for a full description of the elements of a functional assessment.

(c) Provide clear, documented findings and written determinations of applicants' Mobility eligibility that are consistent with the ADA and MARTA policies Applicants may be granted unconditional eligibility, conditional eligibility, temporary eligibility, or be denied eligibility. The Contractor will also be required to indicate whether or not future in-person assessments are appropriate on a case by case basis.

(d) Ensure that MARTA staff have sufficient notice to inform applicants of their eligibility status not more than 21 calendar days after the completion of their in-person interview, or not more than 21 calendar days after receipt of the ~lified recertification form for Clf7p licants , .... ho have alread~{ com Flleted an in p€f5ef\ completion of their recertification interview, and respond to questions from applicants regarding eligibility determinations. See Section 12 "Anticipated Timeline" below for additional guidance in meeting this goal.

(e) Identify applicants for participation in MARTA's travel training program. The criteria used to select persons for travel training shall be subject to the review and approval by MARTA.

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(f) Make accommodations to effectively communicate with applicants in languages other than English, including sign language, during in-person interviews. The Contractor may require applicants to request such assistance at least 48 hours in advance.

(g) If disability-related aids and/or services are required, the Contractor shall provide them . The Contractor may require applicants to request such aids at least 24 hours in advance. These aids and services may include, but not be limited to:

a. Sign language interpretation

b. Braille

c. Large print type

d. TDD (telecommunications display device)

e. Others as required

(h) Participate in all paratransit eligibility appeals hearings as deemed necessary by MARTA.

(i) Provide accurate and timely invoices with a summary sheet and a breakdown of charges by client.

(j) The Contractor shall participate in a minimum of four (4) community outreach sessions at the commencement of the Contract to be conducted by MARTA, to assist MARTA in (a) explaining how the new paratransit eligibility assessment process will be conducted, and (b) the transition of the services under the Contract.

(k) Proposals should address any computer application needs that pertain specifically to the conduct of assessments to be performed by the contractor as outlined in this request for proposals.

(I) Electronic formats are preferred. File types and formats should be indicated in proposals. Note the following list for examples of content and frequency:

A Daily Appointment log will be maintained that lists:

• All scheduled appointments by day • If applicants subsequently called and cancelled appointment • If applicants no-showed appointments • If appointments were kept.

A Daily Activity log in electronic format that will show the number of:

• Appointments for the day • Appointments no-showed or cancelled • Intakes and interviews conducted • Indoor assessments completed • Outdoor assessments completed • FACTS tests administered • MMSEs administered • Individual applicants interviewed/assessed • Completed documentation and files transmitted to MARTA that day (not necessarily for the applicants seen

that day)

An Eligibility Recommendation report for each applicant, including:

• Applicant Name • MARTA ID number

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• Date of completed determination • Recommended eligibility determination • Disability code • Assessment type (e.g. physical, interview etc.) • Name of assessor conducting the assessment

On a monthly basis, the contractor will also provide:

• A breakdown of the number of completed files transmitted to MARTA indicating the elapsed time from the appointment to the file transmittal (i.e., # completed in one business day, # completed in two business days, etc.) [Note: You may want Becky's unit to maintain this information]

• A memo detailing the reasons for any completed files not being transmitted in two business days. • A narrative identifying any atypical occurrences for the day, including any accidents or incidents, or major

equipment failures or facility issues, etc.

11. Description of Functional Assessments: The Contractor shall perform all functional (physical [including, without limitation visual) and/or cognitive/psychological) assessments. The physical ability assessment shall evaluate strength, balance, coordination, endurance, range of motion, and distance, and may include simulated trips to and from a bus or train stop, boarding a bus/train, negotiating a curb or curb cut, and crossing a street. For a full description of the elements involved in a physical functional assessment, the Proposer is referred to "Determining ADA Paratransit Eligibility: An Approach, Guidance and Training Materials," which can be obtained from the Easter Seals Project ACTION office at (800) 659-6428.

The cognitive/psychological ability assessment shall evaluate orientation, safety awareness, memory, learning skills, problem solving, navigation skills, and motivation, and may include testing an individual's ability to make simple and complex trips; tests of abstract thinking abilities such as memory, judgment, and self-initiation; resistance to distraction; impulse control; and communication. The FACTS test which has specifically been developed to conduct this evaluation is recommended but not required, subject to MARTA approval of another test or method proposed by the Contractor. For more information on the FACTS test, see:

http://prolectacti on. eastersea IS.com(site(DocServer (FACTS Series. pdf?docID=9823.

The visual ability assessment shall determine whether an applicant's visual disability prevents them from using MARTA's bus and rail system. It is anticipated that for applicants who are legally blind (based on the visual acuity statement provided by the applicant), the Contractor will provide the services of an Orientation and Mobility Specialist to conduct the assessments.

For individuals whose application is based on seizures or psychiatric disability, the contractor will not conduct functional assessments unless other disabilities are also indicated, but will be required to conduct an in-person interview.

Determinations in these cases will be based on information provided by the applicant and their medical provider, with possible follow-up via telephone to the medical provider.

Contractor shall grant MARTA access to monitor the assessment process at any time as requested by MARTA, and anticipates conducting random evaluations of eligibility determinations on a regular basis in order to ensure quality control.

12. Anticipated Timeline:

Applicants (new and recertifying who have not previously participated in an in-person interview) will need to complete an in-person interview and will be notified of the eligibility determination within 21 calendar days of doing so. Critical variables for the Contractor to meet this deadline include, but are not necessarily limited to :

• MARTA Eligibility Staff will coordinate interview appointments to be scheduled for no later than 7-10 days upon

of reception of completed application

• The 21 day contract compliance time frame begins when Contractor conducts the interview/assessment

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• It is anticipated that some determinations can be made immediately following the interview and/or assessment

• Some cases may require input from external entities (Le., medical professionals, etc.)

• MARTA Eligibility staff will require a reasonable time period to communicate determinations to applicants to

complete the cycle

Timely determinations, in accordance with ADA requirements, are a material term of the Contract and are considered paramount for a successful program.

13. Contractor Staffing:

The Services described in this Contract will require, at a minimum, that the contractor provide, in addition to the other Contract requirements, the following:

• A Project Manager who will report to MARTA's Eligibility Coordinator;

• A sepa rate Agreement Agree to use the MARTA Mobility Center for all assessments;

• Professional staff to perform interviews and functional assessments, who shall include the following:

Certified physical therapist, occupational therapist, rehabilitation, orientation and mobility specialist,

expert in cognitive and psychiatric impairments; and/or;

Professional staff with Bachelor's Degree in a social services, rehabilitation or ancillary health care

profession or a related field and a minimum of 3 years of experience relating to the provision of

professional services to persons with disabilities or older adults.

14. Estimated Future Assessments:

The number of estimated certification applications or renewals /recertification's provided in this section is based on MARTA's past experience and future projections, and is intended to provide Proposers with an estimate of the work involved. MARTA does not guarantee this level of applications or recertifications during the term of the contract, and the actual type and number of assessments may differ from these estimates.

As of the effective date, more than 11,000 individuals are currently registered with MARTA Mobility, of whom approximately 6,289 have used the service in the past year. MARTA currently processes over 375 applications (both new and recertifications monthly) approximately 300 new applications rno~ However, it is important to note that future application volumes need to take into account the more extensive requirements of a more thorough and accurate in-person assessment.

As a result, the anticipated volume of assessments for this Contract is in the range of 3,600-4,000 per annum (both new applications and recertifications), or an average of about ~ 18 assessments per weekday. During the first three years of the contract, recertifications are expected to represent g.§% 60% of total assessments, Slit th is proportion-wi+kJ.i:efHl"ft:eF ~rrent registrants who reapply ha',ce been recertified within three years of init iation of rccertificati-9f1!7 this volume is driven by the proposed move from a four (4) year to three (3) year recertificaton eye/e. Should that proposal not come to fruition the yearly totals of recertification transactions would drop accordingly.

Contractor acknowledges and agrees that it is responsible, at its sole cost and expense, to complete all interviews, functional assessments, cognitive assessments and O&M visual assessments regardless of the time required to complete the same. Contractor is advised, fo r informati ona l purpos s only, that in peer system s, the amount of time required for in-person assessments typically falls within the following ranges :

• About 20 to 30 minutes for an interview only

• About 30 to 60 minutes for a physical functional assessment, including handling of paperwork

• In-person assessments for people with cognitive disabilities usually take between 40 and 70 minutes, including

the interview and physical assessment (although this usually involves a small percentage of applicants, as many

people are found eligible based on a FACTS test alone, without having to conduct the outdoor physical

assessment) Page 57 of 65

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Attachment A

Instructions Price Proposal Form RFP P36410

Thl~ Excei file "HFP P36410 Price 'roposal Form-rl1.xlsx·' wiil be used to submit your proposal pricing. 1 here are 3 tabs to be used as follows:

1. Unit Detail -. for reference only. This tab contains projected numbers of work units and must not be changed by proponent. This data is used to populate the Price Proposal Form fields "Estimated

Units ..

Z. Mobilization Detail - This tab allows proponets to enter dollar values for several categories of mobilization costs to be recorded and summed. The summed total of mobilization costs will populate the

"MObilization" Field on the Price Proposal Form

3. Price Proposal Form - This tab aggregates data from the Unit Detail and Mobilization Detail tabs and permits proponents to enter remaining data as follows:.

On ,his worksheet proponents will need to enter th,e Monthly Administrative Fee for each yearon row 9.

Proponents will enter their unit prices for each activity's unit price, for each year, on rows 13, 16, 19, 22.

Rows 28-47 tabulate all dala and provide annual and 5-year costs. This section "ANNUAL AND TOTAL BID PRICE" is formatted to print easily for submissions of proposals.

Please include belli a hardcopy printout of -ANNUAL AND TOrAt BID PRICE" and th~Attuchmetlt A fEllcel me) " with your proposal. Attachment A should be provided via disk or USB.

l> ,(,

PRICE PROPOSAL FORM - ENTER COSTS INTO HIGHLIGHTED CELLS ONLY ANNUAL AND TOTAL BID PRICE - CALCULA TEDI DO NOT EDIT CELLS

Mobilization

Monthly Overhead Fee

Assessment Costs: Interview (including MMSE) Interview with Functional Assessment

Interview with Cognitive Assessment

Interview with a & M Visual Assessment

Total Annual Costs:

Contract Year: Year 1

Starting Date:

Not to Exceed

Year 2 Year 3

$0

$0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0

OPTION YEARS

Year 4 Year 5

$0

$0 $0 $0 $0 $0

$0

TotalS-Year Bid Price:

$0

$0 $0 $0 $0 SO

$0

~

~

MOBILIZATION COSTS

Costs anticipated to be incurred by the contractor between Notice to Proceed and "Start Date"

Please refer to Response to Inquiry #1, Question 10

Administrative Personnel

Staff Wages/Fringes

Supplies

Computer Hardware

Computer Software

Communications Systems

General Insurance

Other

Mobilization Cost Subtotal: $0

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Attachment B

SUBJECT:

Dear Applicant:

marta 2424 Piedmont Rd. N.E. Atlilllta, CiA 30324-3330 404-848-5000

COMPLETION OF APPLICATION FOR ADA MOBILITY ELIGIBILITY

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MARTA has received your Application for ADA Mobility Eligibility. Upon review of your application, we find that certain information was not provided, as indicated below.

___ Application is not signed by applicant and/or guardian on Authorization page

___ Authorization for the health care professional to release information is not signed by applicant and/or guardian

___ Health care professional's information is not complete. Please specify full name, address (including clinic name and floor if a hospital) and phone number

Note: For your convenience, we have highlighted the areas requiring your attention.

Please complete and return the enclosed application as soon as possible to:

MARTA Mobility Services 2424 Piedmont Road, NE Atlanta, GA 30324-3330

If you have any questions, please call the MARTA Mobility Eligibility Department at (404) 848-5389 (Voice) or -711 (Georgia Relay Service) and ask to speak with me. If I am not in for the day, someone else in our department will be happy to help you.

Sincerely,

Geraldine Person Mobility Eligibility Service Agent

METROPOLITAN ATLANTA RAPID TRANSIT AUTHORITY www.it.lmorto.com

December 11, 2015

Subject: Inactive Status

DearMs._:

marta 2424 Piedmont Rd. N.E. Atlanta, GA 30324-3330 404-84S-5000

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The Metropolitan Atlanta Rapid Transit Authority (MARTA) appreciates your interest in our Mobility services. We received Part A of your application and faxed Part B on November 18, 2015 and December 09,2015 to Dr. Dickens' fax at (404) 778-2730. The office number we have on file is (404) 778-2700. Please confirm the contact information with your Health Care Professional.

According to our records, your application is inactive because your Health Care Professional has not returned a completed Part B form to our office. The application process requires a completed application, Parts A and B. Ifwe do not receive a response from you or your Health Care Professional (listed above) within thirty (30) days of this letter, your file will remain in an "inactive" status.

If you have any questions or concerns, please contact MARTA Mobility Eligibility Department at (404) 848-5389 (Voice) or 711 (Georgia Relay Service) and ask to speak with me. If] am unavailable, another eligibility agent will assist you.

Sincerely, ,

!.' '

" (, ), i>i Ii / i. ," {

Geraldine Person MARTA Mobility Eligibility Service Agent

METROPOLITAN ATlANTA RAPID TRANSIT AUTHORITY www. it~morto.com

Dear Health Care Professional :

marta 2424 Piedmont Rd. N. E. Atlanta, GA 30324-3330 404-848-5000

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The Americans with Disabilities Act (ADA) of 1990 is a civil rights bill which prohibits discrimination against persons with disabilities. In accordance, MARTA is required to provide comparable (paratransit) transportation for individuals who, because of their disability, cannot travel by fixed route (bus or rail) service. MARTA's regular bus and rail service is wheelchair accessible and operators make the required ADA announcements to assist the visually impaired. Many disabled individuals use our system daily; however, a percentage of patrons cannot travel on regular buses or the rail system. Individual categories applying to these patrons are described below.

One of your clients has requested certification for use of MART A Mobility Services. Your assistance is required for evaluating and properly detennining the applicant's ability or inability to use MARTA's regular bus and/or rail service. Please complete the attached Health Care Professional Certification (Part B) of the Application for MARTA Mobility Services and fax your reply to MARTA.

The law specifically defines the conditions of eligibility for paratransit (MARTA Mobility) transportation. We hope that the descriptions below will aid your understanding of the eligibility criteria. The three categories of eligibility are defined as follows:

Category 1 : Individuals with disabilities who cannot board, tide or disembark from an accessible vehicle (e.g., people who, because of a visual or cognitive impairment, could never "navigate the system"). These individuals arc usually paratransit dependent for life.

Category 2: Individuals with disabilities who can use an accessible vehicle (bus or rail) but an accessible vehicle is not available. These individuals are usually transitional users until the system becomes 100% accessible.

Category 3: Individuals with disabilities who have specific impaiLment related conditions which prevent them from getting to and from a bus stop. A combination of a disability and environmental barriers (such as a blind person who cannot cross an eight lane highway or a wheelchair user who cannot go up a steep hill or push through heavy snow) may prevent a person from getting to and from a stop. The existence of a balTier alone, however, does not confer eligibility. Inconvenience and decreased comfoJi are not a basis for qualification. The condition must prevent the travel.

Should you need additional information or explanation, plcase call our Eligibility and Certification Specialist for assistance at (404) 848-5389. Please fax your reply to us within three (3) days. We appreciate your timely response to this request as the ADA law requires a twenty onc (21) day turnaround on application processing.

Sincerely,

Rebecca Rcumaun, M.A., M.S. Mobility Eligibility Specialist

If any questions, please contact me, Geraldine Person, at (404) 848-5789. Thank you!!

METROPOLITAN ATLANTA RAPID TRANSIT AUTHORITY www.itlmorto.com

FAX IZl Urgent 0 For Review

Date: 0 9 - 0 3 - 2015

To: , [vI. D.

I:8J Please Reply

2424 Piedmont Rd. N. E. Atlanta, GA 30324-3330

Phone/Fax:

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From: Geraldine Person Phone/Fax: 404 - 8 48 - 4081/4 - 8 48 - 6 900

Re: MARTA Mobility Eligibility Application No. of Pages: 5

Comments: FAX Confidential: If this fax was sent to you in error, please call or return to MARTA

Mobility. Otherwise, please complete and fax back to us ASAP-within 3 business days. Thank

you!

Eligibility Information for:

NAME:

SSN: xx

OOB:

METROPOLITAN ATLANTA RAPID TRANSIT AUTHORITY WWW.ltsmarla.com

MARTA l\10BJLJTY APPLfCATION FOR PARATHANSIT ELIGIBILITY

DEAR APPLICANT: PLEASE READ BEFORE COMPLETING

The questions in Part A of this application represent the tirst step in the process to certify your application for eligibility to use MARTA Mobility Service (i.e., paratransit). Please answer every question, as each will assist MARTA in detennining the appropriate service that matches your abilities.

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It is your responsibility to return this first step of the Certification Process (PART A) to MARTA completed and properly signed. You must sign the Authorization Page of PART A. Your signature authorizes your Health Care Professional to release information about your disability. At the top of the Authorization Page, please provide the name, address, and phone number of the Health Care Professional who can appropriately answer questions about your disability and ability to travel. MARTA will forward Part B the same day Part A is received in our office.

Your application is complete once your Health Care Professional has completed and returned PART B to MARTA. PART A-APPLICANT lNFQRMATJON (PLEASE PRINT) DATE: _ ____ _

PLEASE CHECK ONE: INITIAL APPLICATION 0 RE-CERTIFICATION APPLICATION 0

NAME LAST ________________ ___ I?IRST ______________ MI _ _ TITLE

ADDRESS: (# STREET) (APT #)

(CITY) (STATE) (ZIP) (COUNTY)

NAME OF SUBDIVISION OR APARTMENT COMPLEX: _________________ _

NEAR"EST IVIA.IOR INTERSECTING STREET: __ _

NEAREST CROSS STREET TO YOUR RESIDENCE:

'ELI. PIIONE #: nOME PHONI~ #: ( ) ( )

FOH II) PURPOSES ONLY: SS # (OPTIONAL)

WORK PHONE #: ( )

DOB:

WHAT IS YOUR DISABILlTV'?

IS THIS CONDITION TEMPORARY? YES 0 NO 0 IF YES, HOW LONG DO YOU ANTICIPATE YOUR DISABILITY WILL AFFECT YOU?

HOW DOES THIS CONDITION AFFECT YOUR ABILITY TO ruDE REGULAR FIXED ROUTE BUS SERVICE?

HOW DOES THIS CONDITION AFFECT YOUR ABILITY TO ruDE THE TRAIN?

ARE THERE ANY OTHER PHYSICAl, OR MENTAL D.ISAIHLITIES/CONDITIONS WHICH IMPACT YOUR FUNCTIONAL ABILITY TO RIDE MARTA'S REGULAR BUS OR RAIL SERVICES?

DO ANY OF THE FOLLOWING CONDITIONS AJ<~FECT YOUR TRAVEL:

GOOD DAYS/BAD DAYS __ _ HILLS ---NO CURB CUT --NO SJDEWAl,K __ _ WEATHER/TEMPERATURE SENSITIVITY __ _

CAN YOU WAIT OUTSIDE FOR 10-15 MINUTES UNASSISTED'? YES 0 NO 0 IF NO, EXPLAIN.

HOW FAR CAN YOU WALK WITHOUT THE ASSISTANCE OF ANOTHER PERSON?

___ LESS THAN ONE CITY BLOCK'? ___ THE LENGTH 0:1" ONE FOOTBALL FIELD'!

ON}~ LENGTH OF A FOOTBALL FIELD AND BACK'? ONE LAP AROUND A TRACK'?

200 FT. 300 FT. 600 FT.

+1200 FT.

DO YOU USE A MOBn~ITY DEVICE TO TRAVEL? PLEASE CHECK ALL THAT APPLY;

WHITE CANE

--- OHTHOJ>EDIC CANE (THREE OR FOUR PRONG BASE) WA]~KER

BRACES ---CRUTCHES

___ MANUAL WHEELCHAIR ___ MOTORIZED WHEELCHAIR

SCOOTER

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IS YOUR SCOOTER/WHEELCHAIR OF STANDARD PROI>ORTIONS'? YES 0 NO 0 IF LARGER, PLEASE SPECIFY.

DO YOU USE A SERVICE ANIMAL? YES 0 NO 0 IF YES, WHAT TYPE Oli' ANIMAIJ AND Ii'OR WHAT PURPOSE WAS THE ANIMAL TRAINED?

DO YOU TRAVEL WITH PORTABLE MEDICAL EQUIPMENT? YES 0 NO 0 WHAT TYPE OF EQUIPMENT'!

DO YOU REQUIRE SOMEONE TO TRAVEL WITH YOU TO PROVIDE PERSONAL TRANSPORTATION ASSISTANCE? YES 0 NO 0 SOMETIMES 0

IF YES OR SOMETIMES, PLEASE TELL US ABOUT THE SPECIFIC ASSISTANCE YOU REQUIRE.

ARE THERE SITUATIONS WHEN YOU WILL NOT REQUIRE TIllS TYPE OF ASSISTANCE? EXPLAIN.

ARE YOU ABLE TO WALK UP 12-14 INCH STEPS UNASSISTED? YES 0 NO 0

CAN YOU GRIP A HANDllAIL TO SUPPORT YOURSELF? YES 0 NO 0

HOW DO YOU TRAVEL NOW? HOW DID YOU GET HERE TODAY? PLEASE CHECK ALL THAT APPLY:

___ WALK DRIVE MYSELF ---PASSENGER IN SOMEONE ELSE'S CAR MARTA'S REGULAR BUS SERVICE ---

___ TRAIN OTHER VAN SERVICE WHICH ONE: ___________ _

WHEN WAS THE IJAST TIME YOU RODE A MARTA BUS?

WHY DID YOU STOP?

WHEN WAS THE LAST TIME YOU RODE ON THE TRAIN'!

WHY DID YOU STOP'!

HAV}~ YOU EVER BEEN TRAINED IN THE USE OF MARTA'S BUS AND RAIL SYSTEM? YES 0 NO 0 WHERE'!

DO YOU FEEL THAT YOl) COULD RIDE THE TRAIN OR nus IF THE VAN COULD GET YOU THERE AND PICK YOU UP FROM THERE?

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NAJVlE AND ADDI ESS OF HEALTH CARE PROFESSIONAL \VITO WILL CERTIFY APPLICATION:

PHONE # ( _________ FAX# (

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TO THE BEST OF MY KNOWLEDGE, THTI INFORMATION I HAVE PROVIDED IN PART A OF THIS APPLICATION lIAS BEEN PROPERLY RECORDED . I HAVE REVIEWED ALL ANSWERS AND CERTIFY THAT THE INfORlvlATION IS COMPLETE AND CORRECT. I UNDERSTAND THAT ANY INTENTIONAL FALSE OR MISLEADING INfORMATION MAY BE GROUNDS FOR DENIAL OF SERVICE. SIGNATURE OF APPLICANT DATE / ----------- - -- - - ----REPRESENT A TIVE OR LEGAL GUARDIAN

IN CASE OF' EMERGENCY CONTACT (IF POSSIBLE, ALTERNATIVE NUMBER, THAN YOUR HOME PHONE).;. NAME __________________________________ _________ __

PHON]<"', # ( ) _ _ _________ CELL # (

IF THIS APP[.fCATT0N HAS BEEN COMPLETED BY SOMEONE OTHER THAN THE APPLICANT, THAT PERSON MUST COMPLETE THE FOLLOWING:

NA~lE ______________________________________________ ___

RELATIONSHIP ---------------------------------------------ADDRESS

HOME PHONE WORK TDD/TTY -------- ---------

T CERTIFY, TO THE BEST OF MY KNOWLEDGE, THAT THE INFOR1vlATION PROVIDED IN THlS APPLICATION IS COMPLETE AND CORRECT BASED UPON THE INFORMATION GIVEN ME BY THE APPLICANT OR MY OWN KNOWLEDGE OF THE APPLICANT'S HEALTH CONDITION OR DISABILITY.

SIGNATURE DATE I

AUTHORIZATION BY APPLICANT TO nELEASE MEDICAL INFORMATION: I, THl: UNDERSIGNED, DO HEREBY CONSENT VIA SJ(iNATlJl<E OF Ti-IIS AUTHORIZATION, '1'1-11 ,: RELLASE OF MEDICAL INFORi'vIATION TO MARTA PARATRANSIT SERVICES FOR THE SOLE PURPOSE OF DETERMINING ADA PARATRANSn ELlG1l3ILITY. 1 UNDERSTAND '1'1 L<\ T T11IS INFORMATION WILL BE SHARED ONLY WITll OTlIER TRANSIT PROVIDERS TO FACILITATE TRAVEL TN THOSE AREAS.

SIGNATURF OF APPLICANT REPRESENTATIVE OR LEGAL GUARDIAN SIGNATURE OF PERSON COMPLETING APPUCArION

DATE

SUBJECT: APPLICATION FOR MOBILITY ELIGIBILITY

Dear Applicant:

marta '2424 Piedmont Rd. N.E. ;'.tlanta, GA 30324-3330 404-848-5000

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The Metropolitan Atlanta Rapid Transit Authority (MARTA) appreciates your interest in our Mobility services. The Americans with Disabilities Act of 1990 (ADA) requires MARTA to provide equivalent public transportation to individuals with disabilities who cannot board, ride, or get to an accessible fixed route bus or train due to their disabilities. This service must be comparable to the service that is provided to individuals without disabilities who use MARTA's regular fixed-route system.

If you have a current diagnosed disability that prevents you from using a MARTA lift-equipped bus or the accessible rail system, you may be eligible for Mobility Services. If your disability does not prevent you from using a lift-equipped bus or the accessible rail system, you may take advantage of MARTA's Reduced Fare program for individuals with disabilities. The card allows you to travel at half the regular fare (currently, $1.00 one-way) on both the bus and rail system. (Alternatively, the Mobility fare is $4.00 each way.) The Reduced~Fare Office number is (404) 848-5112.

Enclosed you will find PART A of the Application for MARTA Mobility. YOU OR YOUR DESIGNEE MUST COMPLETE ALL QUESTIONS and you must sign it to certify that the information is complete and correct. Please be sure that all of the signatures required on the

Authorization page have been Signed by you or your designee. Please return your application in the enclosed envelope.

We will forward PART B of this application to your health care professional upon our receipt of PART A, including the signed Authorization page. PART B must be completed and signed by your physician or other health care professional. Your or your health care professional's failure to return fully completed applications will delay processing. MARTA must process a completed application (PART A and B) within 21 calendar days of receipt. You will receive Presumptive Eligibility to ride MARTA Mobility if the completed application is not processed within 21 calendar days of receipt.

If you have any questions, please call the MARTA Mobility Eligibility Department at (404) 848-5389 (Voice) or -711 (Georgia Relay for Hearing Impaired).

Sincerely, Rebecca R. Reumann, M.A. , M.S. Mobility Eligibility Specialist

Alternative Format available upon request: Email' CD

__ Language (other than English) __

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METROPOLITAN ATLANTA RAPID TRANSIT AUTHORITY www.ilsrnarlo .com

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MARTA MOBILITY 2424 PIEDMONT RD., NE ATLANTA, GEORGIA 30324-3330

December 10, 2015

SUBJECT: APPLICATION FOR MARTA MOBILITY ELIGIBILITY

Dear _ :

ar a 2424 Piedmont Rd. NT Allantu, GA 30324-3330 404-R·1R-SOOO

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MARTA has received your Application for MARTA Mobility Eligibility. Based on the information that you provided, it has been determined that you do not meet the qualifications necessary for us to provide you with service at this time. The reason for the denial of your application is:

Eligibility for complementary paratransit service is directly related to the inability of a person with a disability to use the existing fixed route service. Paratransit service is for "Any individual with a disability who is unable, as the result of a physical or mental impairment (including a vision impairment), and without the assistance of another individual (except the operator of a wheelchair lift or other boarding assistance device), to board, ride, or disembark from any vehicle on the system which is readily accessible to and usable by individuals with disabilities." [Sec. 37.123(e)(1)] Your decreased visual acuity, while it may limit your mobility, does not constitute a disability that currently prevents you from being able to use the regular MARTA bus and rail system. You can walk moderate distances without requiring a mobility aid. You can siUstand up front on the bus and the bus operator can call out stops for you. You can wait outside for 10-15 minutes, unassisted. You are also able to give addresses and phone numbers and you can recognize a destination or landmark. Additionally, you can deal with unexpected changes in your routine, and ask for, understand and follow directions such that you would be able to independently board the next bus or train.

Your residence is served by Rte. #115. Please call MARTA Schedule Information at (404) 848-4711 or log onto www.itsrna rta.com to plan your trip itinerary when you plan to ride MARTA You may apply for a MARTA Reduced-Fare Card to ride the regular bus/train by calling 404-848-5112.

If you do not agree with this decision, you have the right to an appeal. You may call 404-848-5389 or complete the Appeal form attached to this letter and fax it to 404-848-6900 or mail it to:

Appeals Panel MARTA Mobility Services

2424 Piedmont Road, N.E. 30324-3330

Upon receipt of your letter of appeal, MARTA will notify you of the location and time of the appeals hearing. You will have the opportunity to be represented at the hearing and may present information and arguments at that time. Should your disability status change, you may submit a new application for paratransit eligibility.

Sincerely,

Rebecca R. Reumann, MA, M.S. MARTA Mobility Eligibility Specialist

METROPOLITAN ATLANTA RAPID TRANSIT AUTHORITY www itlmortc .<orn

marta 2424 Piedmont Rd, N.E. Atlanta, GA 30324-3330 404-84S-5000

NOTICE OF APPEAL (MARTA Mobility ADA Paratransit Eligibility)

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Notice is hereby given that I, ____________ __ , wish to appeal the decision that denies me the following for which I believe I qualify:

(Check one)

__ ADA Paratransit eligibility: Eligibility to use MARTA Mobility service

__ Unconditional ADA Paratransit eligibility: Conditional eligibility was given

__ Standard-term eligibility: Temporary eligibility was given

Therefore, I request that a hearing date be set by MARTA within twenty (20) days of receiving this Notice, and that I be notified of the time and place of the hearing.

Signature Date

Print legibly or type:

NAME:

ADDRESS: ______________________________ _

PHONE:

Notice of Appeal must be submitted within 60 days of notification of denied eligibility, Please call 404-848-5389 or fax 404-848-6900 or mail this form to:

MARTA Mobility 2424 Piedmont Rd, NE Atlanta, GA 30324-3330

METROPOLITAN ATlANTA RAPID TRANSIT AUTHORITY www.itsmorlo.com