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Orange County Transportation Services ADA Paratransit Plan 41 <br /> PART B—CERTIFICATION OF HEALTH CARE PROVIDER <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 /> 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 /> 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 /> El Compromised Endurance muscular_respiratory El Other(please specify below) <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 /> Orange County Planning Department Page 35 <br />