49 CFR Parts 37 & 38 - Department of Transportation (DOT) ADA Regulations

APPENDIX A TO SUBPART H OF PART 37— SERVICE REQUEST FORM

Form for Advance Notice Requests and Provision of Equivalent Service

1. Operator's name ______________________________________________________

2. Address ______________________________________________________________

________________________________________________________________________

3. Phone number: ________________________________________________________

4. Passenger's name: ____________________________________________________

5. Address: _____________________________________________________________

________________________________________________________________________

6. Phone number: ________________________________________________________

7. Scheduled date(s) and time(s) of trip(s): ________________________________________________________

________________________________________________________________________

8. Date and time of request: ____________________________________________

9. Location(s) of need for accessible bus or equivalent service, as applicable: _____________________________________________________________

10. Was accessible bus or equivalent service, as applicable, provided for trip(s)? Yes -------- no --------

11. Was there a basis recognized by U.S. Department of transportation regulations for not providing an accessible bus or equivalent service, as applicable, for the trip(s)? Yes -------- no --------

If yes, explain _________________________________________________________

________________________________________________________________________

[66 FR 9054, Feb. 6, 2001]