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Orange County Transportation Services ADA Paratransit Plan 35 <br /> Please check all that agply 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 /> 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 /> 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 /> 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 /> The condition is ❑temporary ❑permanent <br /> -------------------------------------------------------------------------------------------------------------------------------- <br /> ❑I have a severe medical condition which limits my ability to function. If checked, describe condition <br /> Orange County Planning Department Page 29 <br />