IndyGo Access - Personal Information Form

Section 3

Please check your responses to the following statements.

I can stand for up to:*

5 minutes
10 minutes
15 minutes
20 minutes
30 minutes
I cannot stand for any period of time

If I am waiting at a bus stop, I must have:*

A bench
A shelter
Neither

When riding Fixed Route buses, I:*

must have a seat
do not need a seat
need the lift deployed
need the bus lowered to step on board
need assistance from the driver to help me board with my mobility aid
None

When crossing a street, I need:*

curb cuts
audible signals
accessible median
tactile curb warnings
I cannot cross a street without help

I can cross a street with:*

2-3 lanes
4-6 lanes
Neither

I cannot make my way across ground that is:*

grassy
hilly/inclined
uneven or has broken sidewalks
gravel or stone
ground type does not affect my mobility

My ability to access transportation is affected by the following weather conditions:*

heat (above 80 degrees)
cold (below 35 degrees)
wind
snow/ice
rain
smog
weather does not affect my ability to access transportation

My ability to access transportation depends on the time of day because I have difficulty seeing:*

in full daylight/sunny days
in partial light/cloudy days
in darkness/semi-darkness
I can see at all hours of the day

The farthest I can walk on level ground and under the best conditions within a reasonable amount of time on my own WITHOUT a mobility aid is:*

half the distance of a football field (150 feet)
the length of a football field (300 feet)
the length of a football field and back (600 feet)
one lap around a track (1,320 feet)

The farthest I can travel on level ground and under the best conditions within a reasonable amount of time WITH a mobility aid is:*

half the distance of a football field (150 feet)
the length of a football field (300 feet)
the length of a football field and back (600 feet)
one lap around a track (1,320 feet)

. I can safely and independently walk up and down (3) 12 inch steps:

Yes
No

When traveling in the community, I travel:*

Alone
Always with a companion or a personal care attendant
sometimes alone or with a personal care attendant

A personal care attendant (PCA) is someone designated or employed specifically to help the eligible individual meet his or her personal needs and is different from a companion or guest. A PCA typically assists with one or more daily life activities such as providing personal care, performing manual tasks, or providing assistance with mobility or communication.

If you answered with a companion or personal care attendant to assist you in your travels, please describe how this person helps you:

I am able to recognize printed information*

Yes
No
Sometimes

I am able to hear and process spoken words/information*

Yes
No
Sometimes

I am able to ask for and follow directions*

Yes
No
Sometimes

I am able to deal with unexpected situations/changes*

Yes
No
Sometimes

I am able to find my way to and from a destination*

Yes
No
Sometimes

I am able to recognize and board the correct bus*

Yes
No
Sometimes

I am able to ride a simple direct route with no transfers*

Yes
No
Sometimes

I am able to deposit fare or show a bus pass*

Yes
No
Sometimes

IndyGo Access – Personal Information Form

IndyGo Access Personal Information Application

IndyGo Access - Personal Information Form

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