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   <br />  <br />2. Does the applicant’s disability require that he or she travel with an attendant? <br /> <br />_____YES _____NO _____SOMETIMES <br /> <br />Explain: _________________________________________________________________ <br /> <br />________________________________________________________________________ <br /> <br />3. Is there any other medical information we should know in the event of an emergency? <br /> (e.g. hepatitis, tuberculosis, cardiac) ___________________________________________ <br />4. If the person has a cognitive disability, is he or she able to give name, address, and <br />telephone numbers upon request? <br /> <br />_____YES _____NO _____SOMETIMES <br /> <br />Explain: __________________________________________________________________ <br />Recognize a destination or landmark? <br /> <br />_____YES _____NO _____SOMETIMES <br /> <br />Explain: <br />_________________________________________________________________________ <br /> <br />5. If the person is speech impaired, is he or she able to communicate verbally? <br /> <br />_____YES _____NO _____SOMETIMES <br /> <br />Explain: <br />_________________________________________________________________________ <br /> <br />I verify that the information provided above for verification is true and correct to the <br />best of my knowledge. <br /> <br />________________________________________________________________________ <br />Signature of Qualified Professional Date <br />31