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Orange County Transportation Services ADA Paratransit Plan <br /> <br />Orange County Planning Department Page 29 <br /> <br />Please check all that apply of the following statements which best define the nature of your disability or <br />limitation that prevents you from using fixed-route bus service. Describe your specific needs in the space <br />provided. <br />☐I have a mobility impairment which prevents me from getting to and/or getting on a fully accessible <br />vehicle without assistance. If checked, describe the nature of this condition and any environmental <br />obstacles (such as inclines, curbs, and distances) which affect your ability to access public transportation. <br />(MOB) <br /> <br /> <br /> <br />The condition is ☐temporary ☐permanent <br /> <br />☐I have an endurance problem which prevents me from moving the distance needed to get to the bus <br />stop. If checked, describe the cause and nature of this condition. (END) <br /> <br /> <br /> <br />The condition is ☐temporary ☐permanent <br /> <br />☐I have a visual impairment that prevents me from finding my way to and from a fixed-route bus <br />stop without assistance. If checked, describe nature of your condition and your functional level of <br />vision. (VIS) <br /> <br /> <br /> <br />The condition is ☐temporary ☐permanent <br /> <br />☐I have a cognitive disability which prevents me from remembering and understanding the <br />information needed to get myself safely to and from the bus stop. If checked, describe the origin <br />and characteristics of your condition. (COG) <br /> <br /> <br /> <br />The condition is ☐temporary ☐permanent <br /> <br />☐I have a severe medical condition which limits my ability to function. If checked, describe condition <br />39