Scooter and Wheelchair Travel Pass - Public Transport Victoria

Scooter and WheelchairTravel PassInformation and application formptv.vic.gov.au

Scooter and Wheelchair TravelPass informationIntroductionThe Scooter and Wheelchair Travel Pass is for people with apermanent and severe disability (being for the term of their lifeand not expected to improve) who depend on the use of ascooter or wheelchair for mobility outside of their home.The information included in this form is intended to assistthe applicant and their General Practitioner or specialistin understanding eligibility for the Scooter and WheelchairTravel Pass.The following is included in this form:• Scooter and Wheelchair Travel Pass information.• Scooter and Wheelchair Travel Pass application form.What is the Scooter and WheelchairTravel Pass?It is a free travel pass for people in scooters or wheelchairsusing public transport.Scooter and Wheelchair Travel Pass – Information and application form 2

Why has the Scooter and Wheelchair TravelPass been introduced?The Scooter and Wheelchair Travel Pass has been introducedto support independent travel for people who are dependenton scooters or wheelchairs.The Scooter and Wheelchair Travel Pass is linked to progressby the Victorian Government in implementing the DisabilityDiscrimination Act 1992 and the Disability Standards forAccessible Public Transport 2002.The Scooter and Wheelchair Travel Pass may be withdrawnor altered at anytime.Please note:• The Victorian Government acknowledges that in someinstances applicants may hold both a Multi Purpose TaxiProgram card and a Scooter and Wheelchair Travel Pass.• For your reference we have included the DisabilityStandards for Accessible Public Transport 2002 for Scooterand Wheelchairs (dimensions, stability or manoeuvrability)in Section 5 of this application form.• If your application is approved and your scooter orwheelchair is outside of these standards, there is noguarantee that your scooter or wheelchair will be ableto access all forms of public transport.Who administers the Scooter and WheelchairTravel Pass?Public Transport Victoria (PTV) is responsible for issuingVictoria’s public transport free travel passes, including theScooter and Wheelchair Travel Pass.Scooter and Wheelchair Travel Pass – Information and application form 3

How do I apply for the Scooter andWheelchair Travel Pass?This application form must be completed by the applicant orwhere the applicant is unable to complete and / or sign theform, by their guardian or agent. Information must also beprovided by the applicant’s General Practitioner or specialist.Additional information from specialists may also be required.Once completed the application form should be submittedto PTV for processing.All applications will be reviewed by the Scooter and WheelchairTravel Pass Panel for eligibility. Where eligibility is unclear,additional information may be sought from the applicant and/ortheir General Practitioner or specialist.The Scooter and Wheelchair Travel Pass Panel and PTVmay also seek independent medical or specialist advice onparticular applications. Any additional testing required by theScooter and Wheelchair Travel Pass Panel and / or PTV will beundertaken at the applicant’s expense.How much does the Scooter and WheelchairTravel Pass cost?The Scooter and Wheelchair Travel Pass is free of charge.Scooter and Wheelchair Travel Pass – Information and application form 5

How do I obtain a replacement card?The pass holder must advise PTV as soon as possible ifthe Travel Pass is lost, stolen, non-operational or damaged,including if they become aware that the name or photographis illegible. A free replacement Travel Pass will be issued.Please note: A statutory declaration must be completedand submitted to PTV for all lost or stolen travel passes.What is the role of the Scooter andWheelchair Travel Pass Panel?The Scooter and Wheelchair Travel Pass Panel has beenestablished to advise PTV on the eligibility of the applicantand the information submitted.Scooter and Wheelchair Travel Pass – Information and application form 6

Scooter and Wheelchair Travel Passapplication formHow to applyStep 1Before completing the application form it is important thatthe applicant read and understand the information containedin this form, in particular:Scooter and Wheelchair Travel Pass information• What is the Scooter and Wheelchair Travel Pass?• Who is the Scooter and Wheelchair Travel Pass for?• Why has the Scooter and Wheelchair Travel Passbeen introduced?• Who administers the Scooter and Wheelchair Travel Pass?• How does the Scooter and Wheelchair Travel Pass work?• Where can I use the Scooter and Wheelchair Travel Pass?• How do I apply for the Scooter and Wheelchair Travel Pass?• What is the role of the Scooter and Wheelchair TravelPass Panel?Disability Standards for Accessible Public Transport 2002– Section 5 (page 20)Scooter and Wheelchair Travel Pass Terms of use –Section 6 (page 22)Scooter and Wheelchair Travel Pass Privacy notice –Section 7 (page 24)Scooter and Wheelchair Travel Pass – Information and application form 7

Step 2Applicant / Guardian / Agent to complete this application form.Step 3Obtain ONE (recent within three months) high quality, colourpassport-size photograph (from a passport photo outlet).Step 4Have Section 2 completed and signed by your GeneralPractitioner or specialist, if applicable.Step 5Have the reverse of the photograph signed by the sameGeneral Practitioner or specialist who completed Section 2.If you are not required to complete Section 2 of the applicationform, then the reverse of the photograph must be signed bya person who can witness statutory declarations.A list of persons who can sign statutory declarations can befound on the website justice.vic.gov.au/justices.Step 6Applicant / Guardian / Agents need to read Section 5 thatoutlines the Disability Standards for Accessible PublicTransport 2002.Scooter and Wheelchair Travel Pass – Information and application form 8

Step 7Return this application form to:The PTV HubAt 750 Collins Street, Docklands, VIC 3008.or mail toPublic Transport VictoriaScooter and Wheelchair Travel Pass applicationsPO Box 4724Melbourne VIC 3001Please note:• Original applications and photographs cannot be returnedunder any circumstances.• Incomplete applications, including those without signaturesor signed photographs, cannot be processed.Scooter and Wheelchair Travel Pass – Information and application form 9

How to complete this formApplicants• All applicants are required to complete Section 1 andSection 3.• All applicants are required to attach the signed photograph– Section 4.Guardian / Agents• If you are completing and signing this application formon behalf of the applicant you are required to completeSection 1, Section 3 and Section 4.General Practitioner or specialist• The General Practitioner or specialist is required tocomplete Section 2 and sign the reverse of the photograph.Please complete this application form in BLOCK LETTERSusing blue or black pen.Scooter and Wheelchair Travel Pass – Information and application form 10

Section 1: Applicant informationThe Scooter and Wheelchair Travel Pass will only be issued tothe person whose details appear below. One application mustbe completed per applicant.Please tick all relevant boxes where applicable.1.1 Applicant’s detailsTitle: Mr Mrs Miss MsSurname or family name:First or given name:Date of birth: / / Male FemaleResidential address:Suburb:State:Postcode:Postal address:Suburb:State:Postcode:Phone – home:Phone – mobile:Email (if available):Scooter and Wheelchair Travel Pass – Information and application form 11

1.2 Are you a permanent resident of Victoria?YesNo1.3 Have you previously applied for the Scooter andWheelchair Travel Pass?YesNo1.4 Why are you applying for the Scooter and WheelchairTravel Pass?1.5 Do you have a Multi Purpose Taxi Program(MPTP) card?Yes: please complete your MPTP number below:9 0 3 6 0 0 3 2 3If you answered Yes, proceed to question 1.6No: please complete:• Section 2 General Practitioner / specialist declaration*• Section 3 Applicant / Guardian / Agent declaration and• Section 4 Photograph, of the application form.Scooter and Wheelchair Travel Pass – Information and application form 12

1.6 If you answered Yes to question 1.5, please advise:When you applied for the Multi Purpose Taxi Program(MPTP) did a General Practitioner or specialist certifyfor the MPTP that you are dependent on a wheelchairfor mobility outside the home:Yes: please complete:• Section 3 Applicant / Guardian / Agent declaration and• Section 4 Photograph, ensuring a justice of the peacesigns the back of your passport photograph.No: please complete:• Section 2 General Practitioner / specialist declaration*• Section 3 Applicant / Guardian / Agent declaration and• Section 4 Photograph, of the application form.* Please note: For those applicants completing Section 2,please bring your passport photograph with you to yourGeneral Practitioner or specialist, as they must sign thereverse of your photograph.Scooter and Wheelchair Travel Pass – Information and application form 13

Section 2: General Practitioner orspecialist’s declarationPlease ensure that all sections are completed to prevent theapplication being returned to you and delay in processingthe application. Your complete answers to questions are criticalin the assessment of the applicant’s eligibility.Please tick all relevant boxes where applicable.Assessment2.1 Does the applicant permanently (being for the term oftheir life and not expected to improve) depend on theuse of a wheelchair for mobility outside their home,due to their disability?YesNoOR2.2 Does the applicant permanently (being for the term oftheir life and not expected to improve) depend on theuse of a scooter for mobility outside their home, dueto their disability?YesNoScooter and Wheelchair Travel Pass – Information and application form 14

2.3 Please provide comment below if there is any furtherrelevant information you would like to add.2.4 Please indicate in what capacity you have madethis assessment.General PractitionerSpecialistPlease note: Remember to sign the back of theapplicant’s passport photograph, certifying it is a truelikeness of the applicants (state their full name).2.5 My signature which appears on the next pageconfirms all of the following:• I have read all the information provided by the applicanton this form and verify that it is correct to the bestof my knowledge.YesNo• I am not the applicant or an immediate family memberof the applicant.YesNo• I agree to offer all reasonable information to assist theScooter and Wheelchair Travel Pass Panel to determinethe applicant’s eligibility.YesNo• I have signed the reverse of the applicant’s photographand confirm it is a true likeness of the applicant.YesNoScooter and Wheelchair Travel Pass – Information and application form 15

2.6 General Practitioner or specialist detailsName:Employer / business name:Business address:Suburb:State:Postcode:Business phone number:Signature:Date: / /Australian Health Practitioner Regulation Agency(AHPRA):AHPRA registration number:Professional stamp:Scooter and Wheelchair Travel Pass – Information and application form 16

Section 3: Applicant / Guardian /Agent declarationPlease tick all relevant boxes where applicable.3.1 I confirm that the signature on the next page verifiesthe following:• I have a permanent and severe disability (being for theterm of my life and that is not expected to improve)which means that I am required to use a scooter orwheelchair for mobility outside my home.YesNo• I authorise public transport authorities to verify theinformation contained in this form, and to obtain anddisclose any information relating to this applicationfor the purpose of assessing my eligibility for aScooter and Wheelchair Travel Pass. This may includeobtaining information held by government departmentsand agencies, and disclosing information contained inthis form or obtained in connection with this applicationfor the purpose of assessing eligibility.YesNo• I agree that the General Practitioner or specialist whocompleted Section 2 of this application may discloseinformation about me to Public Transport Victoriato assist with the assessment of my application.YesNo• I declare that the information in this application is correct.YesNoScooter and Wheelchair Travel Pass – Information and application form 17

• I declare that I am a resident of Victoria.YesNo• I have read, and acknowledge the Disability Standardsfor Accessible Public Transport 2002 – Section 5.YesNo• I accept the Scooter and Wheelchair Travel Pass Termsof use – Section 6.YesNo• I have read, or had explained to me, the Scooter andWheelchair Travel Pass Privacy notice – Section 7.YesNoApplicant signature (must be 18 years and over):Date: / /Please note: if the applicant is under 16 years of age, or isunable to sign the application, the applicant’s guardian oragent must complete and sign section 3.2.Scooter and Wheelchair Travel Pass – Information and application form 18

3.2 Guardian / Agent detailsI declare that I have read and explained the contentsof this application to the applicant, and that the detailsof the applicant set out in this application are correct.Guardian / Agent name (and relationship to the applicant)Guardian / Agent phone numberGuardian / Agent signature for applicants unable to sign(must be 18 years and over)Signature:Date: / /Scooter and Wheelchair Travel Pass – Information and application form 19

Section 4: Photograph35mmJOHN SMITHThis photograph is a truelikeness of John Smith45mmMargaret BrownAmcal Pharmacist Glenroy18-8-11A photograph is MANDATORY for ALL applicants.Affix ONE recent (within 3 months) high quality colourpassport-size photograph to the form.The colour passport-size photograph:• must be a clear head shot taken front on.• must have your full name printed on the reverse of thephotograph and signed by the same General Practitioneror specialist who signed Section 2, or by a person who canwitness statutory declarations (if you were not required tocomplete Section 2). See example above.Please note:• A list of persons who can sign statutory declarations can befound on the website justice.vic.gov.au/justices.• Photocopies of photographs or black and whitephotographs will not be accepted.• The photograph is kept on file to make it easier for you toget a replacement Scooter and Wheelchair Travel Pass inthe event it is lost, stolen or becomes non-operational.Scooter and Wheelchair Travel Pass – Information and application form 20

Section 5: Disability Standards forAccessible Public Transport 2002 –scooter or wheelchair sizeThe Disability Standards for Accessible Public Transport2002 are listed below and detail the specifications for publictransport in relation to its capacity to accommodate scootersand wheelchairs.Please note: if your application is approved and your scooteror wheelchair cannot be accommodated within thesestandards, there is no guarantee that your scooter orwheelchair will be able to access all forms of public transport.DimensionsThe mobility aid needs to:• fit within an allocated space of 1300mm by 800mm• be no more than 750mm wide at a height of 300mm abovethe ground to fit between the wheel axles of a bus.The total weight of the passenger, the assistant and themobility aid needs to be less than 300kg. This is to ensurethe total weight does not exceed the maximum capacity ofa boarding device (for example, ramp) which is 300kg.StabilityThe mobility aid needs to:• be able to move in the direction determined by thetransport operator• have effective braking systems to maintain stability.Scooter and Wheelchair Travel Pass – Information and application form 21

ManoeuvrabilityThe mobility aid should be able to:• turn 180 degrees within an area 2070mm by 1540mm• cross a horizontal gap up to 40mm wide• mount a vertical rise (bump) up to 12mm• cross grating gaps up to 13mm wide and 150mm long• negotiate a 1:14 grade unassisted (for example, ramp)• negotiate up to a 1:8 grade where the ramp is lessthan 1520mm• negotiate a 1:4 grade with assistance (for example, ramp).Scooter and Wheelchair Travel Pass – Information and application form 22

Section 6: Terms of useThe Travel Pass entitles the pass holder to free travelon Victoria’s public transport network. The pass holder will beissued with a registered myki with their photograph and nameprinted on the card.As at the date of issue of these terms of use, this means:• train, tram and bus passenger services operatingin metropolitan Melbourne;• train and bus passenger services operated by V/Linethroughout regional Victoria; and• other public transport services operated under contractor service agreement with Public Transport Victoria.Free travel passes do not necessarily apply to NSW TrainLink,Great Southern Railway, airport services, tourist railways,privately run bus services and chartered trains, trams andbuses. Please check with the relevant operator before bookingor travelling.Terms of use:1. Only the person whose photograph and details appearon the Travel Pass is permitted to use the pass.2. The pass holder must carry their Travel Pass at all timeswhen travelling on Victoria’s public transport network.3. The Travel Pass remains the property of PTV.4. Representatives of public transport authorities may inspect,deactivate, suspend, hotlist or take possession of the TravelPass or require its return at any time if thep ass holder is inbreach of the terms of use.Scooter and Wheelchair Travel Pass – Information and application form 23

5. PTV may change these terms of use from time to time.The current version of the terms of use may be obtainedby calling PTV on 1800 800 007. Where TTA reasonablyconsiders that any such change will have more than a minordetrimental effect on travel for pass holders generally, thechange will be notified by PTV to pass holders in advancein writing.6. The pass holder must not alter, tamper or interfere with theTravel Pass.7. The pass holder agrees to advise PTV as soon aspossible if the Travel Pass is lost, stolen, damaged ornon-operational, including if they become aware that thename or photograph is illegible.8. A free replacement Travel Pass will be issued for all lost,stolen, damaged and non-operational travel passes.Please note: A statutory declaration must be completed andsubmitted to PTV for all lost or stolen Travel Passes.Scooter and Wheelchair Travel Pass – Information and application form 24

Section 7: Privacy noticePTV is collecting your personal and health information tofacilitate the assessment of your eligibility for, and issuingand administration of, a Scooter and Wheelchair Travel Pass.Where necessary, PTV may disclose your personal informationto the Department of Transport for purposes associated withthe administration of public transport ticketing laws. Yourpersonal information will otherwise only be used or disclosedby PTV if permitted under privacy law.If you choose not to provide certain information (such as yourname, address, or other contact details) as requested, PTVmay be unable to process your application for a Scooter andWheelchair Travel Pass.You are entitled to contact the PTV Information Privacy Officer(contact details are set out below) and request access to anypersonal information about you, that is held by PTV.PTV will take reasonable steps to correct and update any ofyour personal information that is established to be inaccurate,incomplete or not up to date or provide you with a writtenstatement if such a request is refused.For more information, please refer to PTV’s Information PrivacyPolicy, available at ptv.vic.gov.au, or contact PTV’s InformationPrivacy Officer using the details below:PTV Information Privacy OfficerPO Box 4724Melbourne VIC 3001Phone: 1800 800 007Facsimile: 9027 4704Email: ptvprivacy@ptv.vic.gov.auScooter and Wheelchair Travel Pass – Information and application form 25

Section 8: Contacts formore informationFor all Scooter and Wheelchair Travel Pass enquires you cancontact the following services for assistance:Public Transport VictoriaPhone:Visit staff:Website:1800 800 007 (6am – midnight daily)At the PTV Hub at 750 Collins Street,Docklands, VIC 3008.Open Monday to Friday 8am to 6pm.ptv.vic.gov.auNational Relay Service: 13 36 77Speech-to-Speech Relay Service: 1300 555 727Multilingual informationFor all Scooter and Wheelchair Travel Pass phone enquiriesin languages other than English, please use the followingphone numbers:Arabic 9321 5440 Mandarin 9321 5454Cantonese 9321 5441 Somali 9321 5446Croatian 9321 5442 Spanish 9321 5447Dinka 9321 5452 Sudanese 9321 5453Greek 9321 5443 Turkish 9321 5448Italian 9321 5444 Vietnamese 9321 5449Macedonian 9321 5445All other foreign languages 9321 5450Scooter and Wheelchair Travel Pass – Information and application form 26

Office use onlyPublic Transport VictoriaFree travel pass application number:Date received from applicant: / /Checked by – initials:Date forwarded to Scooter and Wheelchair TravelPass Panel (SWTPP): / /Date received recommendation from SWTPP: / /Scooter and Wheelchair Travel Pass card number:3 0 8 4 2 5Date applicant advised of recommendation: / /Date Travel Pass issued: / /Scooter and Wheelchair Travel Pass PanelDate received from Public Transport Victoria: / /Date recommendation sentto Public Transport Victoria: / /Recommendation: ApprovedDeclinedComments:Initials: Date: / /PTVH0114Scooter and Wheelchair Travel Pass – Information and application form 27