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Orange County Transportation Services ADA Paratransit Plan <br /> <br />Orange County Planning Department Page 35 <br /> <br />PART B – CERTIFICATION OF HEALTH CARE PROVIDER <br /> <br />1. I have read Part A in its entirety and I agree with the information provided. ☐Yes ☐No <br />If no, please explain: <br /> <br /> <br /> <br />2. Identify the disability or health condition preventing the applicant from using HPTS fixed route buses. <br />(Please be specific but use layman’s terms) <br /> <br />3. Specify which functional limitations are associated with this condition and be specific when asked <br />to supply additional information. <br />☐Mobility Impairment ☐Visual Impairment: total partial <br />☐Hearing Impairment total partial ☐Cognitive Impairment <br />☐Compromised Endurance muscular respiratory ☐Other (please specify below) <br /> <br /> <br />a) What is the severity of the individual’s condition? <br />☐Mild ☐Moderate ☐Severe ☐Profound/Chronic <br />b) If this individual has functional limitations due to a cognitive impairment, please indicate any of <br />the following issues that are pertinent to this individual: <br />☐Cannot be left alone to wait for transportation <br />☐Displays behavior that is unsafe for self or others using public transportation <br />☐Cannot recognize vehicles that she/he should board <br />c) What is the expected duration of this individual’s condition? <br />☐Temporary – approximate duration until <br />☐Long term – potential for functional improvement or periods of remission <br />☐Permanent – no expectation of functional improvement <br />4. For any impairment checked above, please note specific precautions that the individual must <br />follow in terms of: <br />45