DART uses this two-page physician questionnaire to judge paratransit eligibility for applicants with a seizure disorder or epilepsy. The physician answers ten questions covering diagnosis and onset, the date of the last seizure, seizure types, medication control, warning signs, triggers, need for emergency care and confusion afterward. DART's eligibility page lists it as the Epilepsy and Seizure Disorder Inquiry.
The applicant enters name, date of birth and the last four digits of the Social Security number. The physician answers every question and signs with printed name and license number and state.
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ADA Paratransit Eligibility Seizure and Epilepsy Verification Form (DART)
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The applicant's physician. The form says it is to be completed and signed by the physician and that every question must be answered. The physician prints their name, signs, and gives a license number and state. The applicant only fills in identifying information at the top.
DART's eligibility page lists the Epilepsy and Seizure Disorder Inquiry among its application forms, alongside the standard and visual-disability certification forms and the Re-Certification Form. All forms go back to DART Paratransit Services, which then schedules the in-person assessment.