Common use of VEHICLE DAILY VEHICLE INSPECTION Clause in Contracts

VEHICLE DAILY VEHICLE INSPECTION. 1. No SNEMT assigned vehicle will be allowed to carry passengers unless the driver has determined that the vehicle is in good working order. Each driver will perform a pre-shift inspection of the vehicle at the beginning of the shift and a post-shift inspection at the end of the shift. A sample of the Vehicle Daily Vehicle Inspection Form is included in Section XI.G A. SNEMT APPLICATION FORM B. SNEMT CLIENT RELEASE FORM/SNEMT PROGRAM WAIVER FORM C. USER FEE WAIVER FORM X. XXXXX INSTRUCTIONS AND CLIENT GUIDELINES E. CLIENT COMPLAINT FORM F. INCIDENT REPORT FORM G. VEHICLE DAILY INSPECTION FORM H. VEHICLE INSPECTION FORM I. INVOICE TEMPLATE J. MONTHLY PERFORMANCE REPORT K. SAMPLE DEMOGRAPHIC REPORT {CONTRACTOR LETTERHEAD} SAMPLE Last Name: First Name: Date: Date of Birth: Age: Male: Female: Address: Apartment/Unit #: City: Zip Code: Home Phone: ( ) Cell: ( ) you Yes 1. Have ever utilized OCTA ACCESS or any other specialized transportation No Yes 2. Do you have any physical or functional limitations? No If yes, please describe: 3. Do you require a mobility device or special equipment for transport? Yes No Please check all that apply: Cane Xxxxxx Wheelchair Scooter Oxygen Other If yes, are you able to enter/exit the vehicle without your mobility device? Yes No Are you able to transfer from a wheelchair to seat with/without assistance? Yes No Will a Yes 4. personal care attendant or assistant be traveling with you? No 5. Do you require door-to-door assistance? Yes No If yes, please describe reasons why: 6. Please list your primary doctor(s) name & address: 7. How often do you anticipate needing to use the transportation service? Weekly Monthly Other 8. Emergency Contact Name: Emergency Contact Relationship: Phone #: 9. How do you get to your medical appointments now? Yes 10. Do you own a vehicle and are you able to drive? No How did you hear about the program? White Other Ethnic background: Asian Black Hispanic Native American Annual Income per individual: • • Referrals to alternative transportation provided: • Reason referred to OoA I&A: • Need for follow-up contact: • Annual Income: At or below AMI Above AMI • Financial Hardship waiver issued:

VEHICLE DAILY VEHICLE INSPECTION. 1. No SNEMT assigned vehicle will be allowed to carry passengers unless the driver has determined that the vehicle is in good working order. Each driver will perform a pre-shift inspection of the vehicle at the beginning of the shift and a post-shift inspection at the end of the shift. A sample of the Vehicle Daily Vehicle Inspection Form is included in Section XI.G A. SNEMT APPLICATION FORM B. SNEMT CLIENT RELEASE FORM/SNEMT PROGRAM WAIVER FORM C. USER FEE WAIVER FORM X. XXXXX INSTRUCTIONS AND CLIENT GUIDELINES E. CLIENT COMPLAINT FORM F. INCIDENT REPORT FORM G. VEHICLE DAILY INSPECTION FORM H. VEHICLE INSPECTION FORM I. INVOICE TEMPLATE J. MONTHLY PERFORMANCE REPORT K. SAMPLE DEMOGRAPHIC REPORT {CONTRACTOR LETTERHEAD} SAMPLE Last Name: First Name: Date: Date of Birth: Age: Male: Female: Address: Apartment/Unit #: City: Zip Code: Home Phone: ( ) Cell: ( ) you Yes) 1. Have you ever utilized OCTA ACCESS or any other specialized transportation No Yes□Yes □No 2. Do you have any physical or functional limitations? □Yes □No If yes, please describe: 3. Do you require a mobility device or special equipment for transport? □Yes □No Please check all that apply: Cane Xxxxxx Wheelchair Scooter Oxygen Other If yes, are you able to enter/exit the vehicle without your mobility device? Yes No Are you able to transfer from a wheelchair to seat with/without assistance? Yes No Will a Yes? 4. Will a personal care attendant or assistant be traveling with you? No? 5. Do you require door-to-door assistance? Yes No If yes, please describe reasons why: 6. Please list your primary doctor(s) name & address: 7. How often do you anticipate needing to use the transportation service? Weekly Monthly Other 8. Emergency Contact Name: Emergency Contact Relationship: Phone #: 9. How do you get to your medical appointments now? Yes? 10. Do you own a vehicle and are you able to drive? □Yes □No How did you hear about the program? White Other Ethnic background: Asian Black Hispanic Native American Annual Income per individual: • •   Referrals to alternative transportation provided: •  Reason referred to OoA I&A: •  Need for follow-up contact: •  Annual Income: At or below AMI Above AMI •  Financial Hardship waiver issued:

VEHICLE DAILY VEHICLE INSPECTION. 1. No SNEMT assigned vehicle will be allowed to carry passengers unless the driver has determined that the vehicle is in good working order. Each driver will perform a pre-shift inspection of the vehicle at the beginning of the shift and a post-shift inspection at the end of the shift. A sample of the Vehicle Daily Vehicle Inspection Form is included in Section XI.G A. SNEMT APPLICATION FORM B. SNEMT CLIENT RELEASE FORM/SNEMT PROGRAM WAIVER FORM C. USER FEE WAIVER FORM X. XXXXX INSTRUCTIONS AND CLIENT GUIDELINES E. CLIENT COMPLAINT FORM F. INCIDENT REPORT FORM G. VEHICLE DAILY INSPECTION FORM H. VEHICLE INSPECTION FORM I. INVOICE TEMPLATE J. MONTHLY PERFORMANCE REPORT K. SAMPLE DEMOGRAPHIC REPORT {CONTRACTOR LETTERHEAD} SAMPLE Last Name: First Name: Date: Date of Birth: Age: Male: Female: Address: Apartment/Unit #: City: Zip Code: Home Phone: ( ) Cell: ( ) you Yes) 1. Have you ever utilized OCTA ACCESS or any other specialized transportation No YesYes No 2. Do you have any physical or functional limitations? Yes No If yes, please describe: 3. Do you require a mobility device or special equipment for transport? Yes No Please check all that apply: Cane Xxxxxx Wheelchair Scooter Oxygen Other If yes, are you able to enter/exit the vehicle without your mobility device? Yes No Are you able to transfer from a wheelchair to seat with/without assistance? Yes No Will a YesNo 4. Will a personal care attendant or assistant be traveling with you? Yes No 5. Do you require door-to-door assistance? Yes No If yes, please describe reasons why: 6. Please list your primary doctor(s) name & address: 7. How often do you anticipate needing to use the transportation service? Weekly Monthly Other 8. Emergency Contact Name: Emergency Contact Relationship: Phone #: 9. How do you get to your medical appointments now? Yes? 10. Do you own a vehicle and are you able to drive? Yes No How did you hear about the program? White Other Ethnic background: Asian Black Hispanic Native American Annual Income per individual: • • Referrals to alternative transportation provided: • Reason referred to OoA I&A: • Need for follow-up contact: • Annual Income: At or below AMI Above AMI • Financial Hardship waiver issued:

VEHICLE DAILY VEHICLE INSPECTION. 1. No SNEMT assigned vehicle will be allowed to carry passengers unless the driver has determined that the vehicle is in good working order. Each driver will perform a pre-shift inspection of the vehicle at the beginning of the shift and a post-shift inspection at the end of the shift. A sample of the Vehicle Daily Vehicle Inspection Form is included in Section XI.G A. SNEMT APPLICATION FORM B. SNEMT CLIENT RELEASE FORM/SNEMT PROGRAM WAIVER FORM C. USER FEE WAIVER FORM X. XXXXX INSTRUCTIONS AND CLIENT GUIDELINES E. CLIENT COMPLAINT FORM F. INCIDENT REPORT FORM G. VEHICLE DAILY INSPECTION FORM H. VEHICLE INSPECTION FORM I. INVOICE TEMPLATE J. MONTHLY PERFORMANCE REPORT K. SAMPLE DEMOGRAPHIC REPORT {CONTRACTOR LETTERHEAD} SAMPLE Last Name: First Name: Date: Date of Birth: Age: Male: Female: Address: Apartment/Unit #: City: Zip Code: Home Phone: ( ) Cell: ( ) you Yes) 1. Have you ever utilized OCTA ACCESS or any other specialized transportation No YesYes No 2. Do you have any physical or functional limitations? No Yes No If yes, please describe: 3. Do you require a mobility device or special equipment for transport? Yes No Yes No Please check all that apply: Cane Xxxxxx Wheelchair Scooter Oxygen Other If yes, are you able to enter/exit the vehicle without your mobility device? Yes No Yes No Are you able to transfer from a wheelchair to seat with/without assistance? Yes No Will a YesYes No 4. Will a personal care attendant or assistant be traveling with you? NoYes No 5. Do you require door-to-door assistance? Yes No Yes No If yes, please describe reasons why: 6. Please list your primary doctor(s) name & address: 7. How often do you anticipate needing to use the transportation service? Weekly Monthly Other 8. Emergency Contact Name: Emergency Contact Relationship: Phone #: 9. How do you get to your medical appointments now? Yes? 10. Do you own a vehicle and are you able to drive? □Yes □No How did you hear about the program? White Other Ethnic background: Asian Black □Asian□Black□Hispanic □White □Native American □Other Annual Income per individual: • • Referrals to alternative transportation provided: • Reason referred to OoA I&A: • Need for follow-up contact: • Annual Income: □At or below AMI □Above AMI • Financial Hardship waiver issued:

VEHICLE DAILY VEHICLE INSPECTION. 1. No SNEMT assigned vehicle will be allowed to carry passengers unless the driver has determined that the vehicle is in good working order. Each driver will perform a pre-shift inspection of the vehicle at the beginning of the shift and a post-shift inspection at the end of the shift. A sample of the Vehicle Daily Vehicle Inspection Form is included in Section XI.G A. SNEMT APPLICATION FORM B. SNEMT CLIENT RELEASE FORM/SNEMT PROGRAM WAIVER FORM C. USER FEE WAIVER FORM X. XXXXX INSTRUCTIONS AND CLIENT GUIDELINES E. CLIENT COMPLAINT FORM F. INCIDENT REPORT FORM G. VEHICLE DAILY INSPECTION FORM H. VEHICLE INSPECTION FORM I. INVOICE TEMPLATE J. MONTHLY PERFORMANCE REPORT K. SAMPLE DEMOGRAPHIC REPORT {CONTRACTOR LETTERHEAD} SAMPLE Last Name: First Name: Date: Date of Birth: Age: Male: Female: Address: Apartment/Unit #: City: Zip Code: Home Phone: ( ) Cell: ( ) you Yes) 1. Have you ever utilized OCTA ACCESS or any other specialized transportation No Yes□Yes □No 2. Do you have any physical or functional limitations? □Yes □No If yes, please describe: 3. Do you require a mobility device or special equipment for transport? □Yes □No Please check all that apply: Cane Xxxxxx Wheelchair Scooter Oxygen Other If yes, are you able to enter/exit the vehicle without your mobility device? Yes No Are you able to transfer from a wheelchair to seat with/without assistance? Yes No Will a Yes? 4. Will a personal care attendant or assistant be traveling with you? No? 5. Do you require door-to-door assistance? Yes No If yes, please describe reasons why: 6. Please list your primary doctor(s) name & address: 7. How often do you anticipate needing to use the transportation service? Weekly Monthly Other 8. Emergency Contact Name: Emergency Contact Relationship: Phone #: 9. How do you get to your medical appointments now? Yes? 10. Do you own a vehicle and are you able to drive? □Yes □No How did you hear about the program? White Other Ethnic background: Asian Black Hispanic Native American Annual Income per individual: • • Referrals to alternative transportation provided: • Reason referred to OoA I&A: • Need for follow-up contact: • Annual Income: At or below AMI Above AMI • Financial Hardship waiver issued:

VEHICLE DAILY VEHICLE INSPECTION. 1. No SNEMT assigned vehicle will be allowed to carry passengers unless the driver has determined that the vehicle is in good working order. Each driver will perform a pre-shift inspection of the vehicle at the beginning of the shift and a post-shift inspection at the end of the shift. A sample of the Vehicle Daily Vehicle Inspection Form is included in Section XI.G A. SNEMT APPLICATION FORM B. SNEMT CLIENT RELEASE FORM/SNEMT PROGRAM WAIVER FORM C. USER FEE WAIVER FORM X. XXXXX INSTRUCTIONS AND CLIENT GUIDELINES E. CLIENT COMPLAINT FORM F. INCIDENT REPORT FORM G. VEHICLE DAILY INSPECTION FORM H. VEHICLE INSPECTION FORM I. INVOICE TEMPLATE J. MONTHLY PERFORMANCE REPORT K. SAMPLE DEMOGRAPHIC REPORT {CONTRACTOR LETTERHEAD} SAMPLE Last Name: First Name: Date: Date of Birth: Age: Male: Female: Address: Apartment/Unit #: City: Zip Code: Home Phone: ( ) Cell: ( ) you Yes) 1. Have you ever utilized OCTA ACCESS or any other specialized transportation No YesYes No 2. Do you have any physical or functional limitations? No Yes No If yes, please describe: 3. Do you require a mobility device or special equipment for transport? Yes No Yes No Please check all that apply: Cane Xxxxxx Wheelchair Scooter Oxygen Other If yes, are you able to enter/exit the vehicle without your mobility device? Yes No Yes No Are you able to transfer from a wheelchair to seat with/without assistance? Yes No Will a YesYes No 4. Will a personal care attendant or assistant be traveling with you? NoYes No 5. Do you require door-to-door assistance? Yes No Yes No If yes, please describe reasons why: 6. Please list your primary doctor(s) name & address: 7. How often do you anticipate needing to use the transportation service? Weekly Monthly Other 8. Emergency Contact Name: Emergency Contact Relationship: Phone #: 9. How do you get to your medical appointments now? Yes? 10. Do you own a vehicle and are you able to drive? □Yes □No How did you hear about the program? White Other Ethnic background: Asian Black Hispanic Native American Annual Income per individual: • • Referrals to alternative transportation provided: • Reason referred to OoA I&A: • Need for follow-up contact: • Annual Income: □At or below AMI □Above AMI • Financial Hardship waiver issued:

VEHICLE DAILY VEHICLE INSPECTION. 1. No SNEMT assigned vehicle will be allowed to carry passengers unless the driver has determined that the vehicle is in good working order. Each driver will perform a pre-shift inspection of the vehicle at the beginning of the shift and a post-shift inspection at the end of the shift. A sample of the Vehicle Daily Vehicle Inspection Form is included in Section XI.G A. SNEMT APPLICATION FORM B. SNEMT CLIENT RELEASE FORM/SNEMT PROGRAM WAIVER FORM C. USER FEE WAIVER FORM X. XXXXX INSTRUCTIONS AND CLIENT GUIDELINES E. CLIENT COMPLAINT FORM F. INCIDENT REPORT FORM G. VEHICLE DAILY INSPECTION FORM H. VEHICLE INSPECTION FORM I. INVOICE TEMPLATE J. MONTHLY PERFORMANCE REPORT K. SAMPLE DEMOGRAPHIC REPORT {CONTRACTOR LETTERHEAD} SAMPLE Last Name: First Name: Date: Date of Birth: Age: Male: Female: Address: Apartment/Unit #: City: Zip Code: Home Phone: ( ) Cell: ( ) you Yes) 1. Have you ever utilized OCTA ACCESS or any other specialized transportation No YesYes No 2. Do you have any physical or functional limitations? No Yes No If yes, please describe: 3. Do you require a mobility device or special equipment for transport? Yes No Yes No Please check all that apply: Cane Xxxxxx Wheelchair Scooter Oxygen Other If yes, are you able to enter/exit the vehicle without your mobility device? Yes No Yes No Are you able to transfer from a wheelchair to seat with/without assistance? Yes No Will a YesYes No 4. Will a personal care attendant or assistant be traveling with you? NoYes No 5. Do you require door-to-door assistance? Yes No Yes No If yes, please describe reasons why: 6. Please list your primary doctor(s) name & address: 7. How often do you anticipate needing to use the transportation service? Weekly Monthly Other 8. Emergency Contact Name: Emergency Contact Relationship: Phone #: 9. How do you get to your medical appointments now? Yes? 10. Do you own a vehicle and are you able to drive? No Yes No How did you hear about the program? White Other Ethnic background: Asian Black Hispanic Native American Annual Income per individual: • • Referrals to alternative transportation provided: • Reason referred to OoA I&A: • Need for follow-up contact: • Annual Income: At At or below AMI Above Above AMI • Financial Hardship waiver issued:

VEHICLE DAILY VEHICLE INSPECTION. 1. No SNEMT assigned vehicle will be allowed to carry passengers unless the driver has determined that the vehicle is in good working order. Each driver will perform a pre-shift inspection of the vehicle at the beginning of the shift and a post-shift inspection at the end of the shift. A sample of the Vehicle Daily Vehicle Inspection Form is included in Section XI.G A. SNEMT APPLICATION FORM B. SNEMT CLIENT RELEASE FORM/SNEMT PROGRAM WAIVER FORM C. USER FEE WAIVER FORM X. XXXXX INSTRUCTIONS AND CLIENT GUIDELINES E. CLIENT COMPLAINT FORM F. INCIDENT REPORT FORM G. VEHICLE DAILY INSPECTION FORM H. VEHICLE INSPECTION FORM I. INVOICE TEMPLATE J. MONTHLY PERFORMANCE REPORT K. SAMPLE DEMOGRAPHIC REPORT {CONTRACTOR LETTERHEAD} SAMPLE Last Name: First Name: Date: Date of Birth: Age: Male: Female: Address: Apartment/Unit #: City: Zip Code: Home Phone: ( ) Cell: ( ) you Yes) 1. Have you ever utilized OCTA ACCESS or any other specialized transportation No YesYes No 2. Do you have any physical or functional limitations? Yes No If yes, please describe: 3. Do you require a mobility device or special equipment for transport? Yes No Please check all that apply: Cane Xxxxxx Wheelchair Scooter Oxygen Other If yes, are you able to enter/exit the vehicle without your mobility device? Yes No Are you able to transfer from a wheelchair to seat with/without assistance? Yes No Will a YesNo 4. Will a personal care attendant or assistant be traveling with you? Yes No 5. Do you require door-to-door assistance? Yes No If yes, please describe reasons why: 6. Please list your primary doctor(s) name & address: 7. How often do you anticipate needing to use the transportation service? Weekly Monthly Other 8. Emergency Contact Name: Emergency Contact Relationship: Phone #: 9. How do you get to your medical appointments now? Yes? 10. Do you own a vehicle and are you able to drive? Yes No How did you hear about the program? White Other Ethnic background: Asian Black Hispanic Native American Annual Income per individual: • •   Referrals to alternative transportation provided: •  Reason referred to OoA I&A: •  Need for follow-up contact: •  Annual Income: At or below AMI Above AMI •  Financial Hardship waiver issued:

VEHICLE DAILY VEHICLE INSPECTION. 1. No SNEMT assigned vehicle will be allowed to carry passengers unless the driver has determined that the vehicle is in good working order. Each driver will perform a pre-shift inspection of the vehicle at the beginning of the shift and a post-shift inspection at the end of the shift. A sample of the Vehicle Daily Vehicle Inspection Form is included in Section XI.G A. SNEMT APPLICATION FORM B. SNEMT CLIENT RELEASE FORM/SNEMT PROGRAM WAIVER FORM C. USER FEE WAIVER FORM X. XXXXX INSTRUCTIONS AND CLIENT GUIDELINES E. CLIENT COMPLAINT FORM F. INCIDENT REPORT FORM G. VEHICLE DAILY INSPECTION FORM H. VEHICLE INSPECTION FORM I. INVOICE TEMPLATE J. MONTHLY PERFORMANCE REPORT K. SAMPLE DEMOGRAPHIC REPORT {CONTRACTOR LETTERHEAD} DocuSign Envelope ID: C5D8E3D8-60B9-4EEE-99F5-398C4C9248C0 A. SAMPLE Last Name: First Name: Date: Date of Birth: Age: Male: Female: Address: Apartment/Unit #: City: Zip Code: Home Phone: ( ) Cell: ( ) you YesCLIENT APPLICATION 1. Have ever utilized OCTA ACCESS or any other specialized transportation No Yes 2. Do you have any physical or functional limitations? No If yes, please describe: 3. Do you require a mobility device or special equipment for transport? Yes No Please check all that apply: Cane Xxxxxx Wheelchair Scooter Oxygen Other If yes, are you able to enter/exit the vehicle without your mobility device? Yes No Are you able to transfer from a wheelchair to seat with/without assistance? Yes No Will a Yes Yes 4. personal care attendant or assistant be traveling with you? No 5. Do you require door-to-door assistance? Yes No If yes, please describe reasons why: 6. Please list your primary doctor(s) name & address: 7. How often do you anticipate needing to use the transportation service? Weekly Monthly Other 8. Emergency Contact Name: Emergency Contact Relationship: Phone #: 9. How do you get to your medical appointments now? Yes 10. Do you own a vehicle and are you able to drive? No How did you hear about the program? White Other Ethnic background: Asian Black Hispanic Native American Annual Income per individual: • • Referrals to alternative transportation provided: • Reason referred to OoA I&A: • Need for follow-up contact: • Annual Income: At or below AMI Above AMI • Financial Hardship waiver issued:

VEHICLE DAILY VEHICLE INSPECTION. 1. No SNEMT assigned vehicle will be allowed to carry passengers unless the driver has determined that the vehicle is in good working order. Each driver will perform a pre-shift inspection of the vehicle at the beginning of the shift and a post-shift inspection at the end of the shift. A sample of the Vehicle Daily Vehicle Inspection Form is included in Section XI.G A. SNEMT APPLICATION FORM B. SNEMT CLIENT RELEASE FORM/SNEMT PROGRAM WAIVER FORM C. USER FEE WAIVER FORM X. XXXXX INSTRUCTIONS AND CLIENT GUIDELINES E. CLIENT COMPLAINT FORM F. INCIDENT REPORT FORM G. VEHICLE DAILY INSPECTION FORM H. VEHICLE INSPECTION FORM I. INVOICE TEMPLATE J. MONTHLY PERFORMANCE REPORT K. SAMPLE DEMOGRAPHIC REPORT DocuSign Envelope ID: 8F0E4DB3-A5A7-42C5-AFEE-FC5805072818 {CONTRACTOR LETTERHEAD} SAMPLE Last Name: First Name: Date: Date of Birth: Age: Male: Female: Address: Apartment/Unit #: City: Zip Code: Home Phone: ( ) Cell: ( ) you Yes 1. Have ever utilized OCTA ACCESS or any other specialized transportation No Yes 2. Do you have any physical or functional limitations? No If yes, please describe: 3. Do you require a mobility device or special equipment for transport? Yes No Please check all that apply: Cane Xxxxxx Wheelchair Scooter Oxygen Other If yes, are you able to enter/exit the vehicle without your mobility device? Yes No Are you able to transfer from a wheelchair to seat with/without assistance? Yes No Will a Yes Yes 4. personal care attendant or assistant be traveling with you? No 5. Do you require door-to-door assistance? Yes No If yes, please describe reasons why: 6. Please list your primary doctor(s) name & address: 7. How often do you anticipate needing to use the transportation service? Weekly Monthly Other 8. Emergency Contact Name: Emergency Contact Relationship: Phone #: 9. How do you get to your medical appointments now? Yes 10. Do you own a vehicle and are you able to drive? No How did you hear about the program? White Other Ethnic background: Asian Black Hispanic Native American Annual Income per individual: • • Referrals to alternative transportation provided: • Reason referred to OoA I&A: • Need for follow-up contact: • Annual Income: At or below AMI Above AMI • Financial Hardship waiver issued:

VEHICLE DAILY VEHICLE INSPECTION. 1. No SNEMT assigned vehicle will be allowed to carry passengers unless the driver has determined that the vehicle is in good working order. Each driver will perform a pre-shift inspection of the vehicle at the beginning of the shift and a post-shift inspection at the end of the shift. A sample of the Vehicle Daily Vehicle Inspection Form is included in Section XI.G A. SNEMT APPLICATION FORM B. SNEMT CLIENT RELEASE FORM/SNEMT PROGRAM WAIVER FORM C. USER FEE WAIVER FORM X. XXXXX INSTRUCTIONS AND CLIENT GUIDELINES E. CLIENT COMPLAINT FORM F. INCIDENT REPORT FORM G. VEHICLE DAILY INSPECTION FORM H. VEHICLE INSPECTION FORM I. INVOICE TEMPLATE J. MONTHLY PERFORMANCE REPORT K. SAMPLE DEMOGRAPHIC REPORT {CONTRACTOR LETTERHEAD} SAMPLE Last Name: First Name: Date: Date of Birth: Age: Male: Female: Address: Apartment/Unit #: City: Zip Code: Home Phone: ( ) Cell: ( ) you Yes) 1. Have you ever utilized OCTA ACCESS or any other specialized transportation No YesYes No 2. Do you have any physical or functional limitations? No Yes No If yes, please describe: 3. Do you require a mobility device or special equipment for transport? Yes No Yes No Please check all that apply: Cane Xxxxxx Wheelchair Scooter Oxygen Other If yes, are you able to enter/exit the vehicle without your mobility device? Yes No Yes No Are you able to transfer from a wheelchair to seat with/without assistance? Yes No Will a YesYes No 4. Will a personal care attendant or assistant be traveling with you? NoYes No 5. Do you require door-to-door assistance? Yes No Yes No If yes, please describe reasons why: 6. Please list your primary doctor(s) name & address: 7. How often do you anticipate needing to use the transportation service? Weekly Monthly Other 8. Emergency Contact Name: Emergency Contact Relationship: Phone #: 9. How do you get to your medical appointments now? Yes? 10. Do you own a vehicle and are you able to drive? No Yes No How did you hear about the program? White Other Ethnic background: Asian Black Hispanic Native American Annual Income per individual: • • Referrals to alternative transportation provided: • Reason referred to OoA I&A: • Need for follow-up contact: • Annual Income: At At or below AMI Above Above AMI • Financial Hardship waiver issued:

VEHICLE DAILY VEHICLE INSPECTION. 1. No SNEMT assigned vehicle will be allowed to carry passengers unless the driver has determined that the vehicle is in good working order. Each driver will perform a pre-shift inspection of the vehicle at the beginning of the shift and a post-shift inspection at the end of the shift. A sample of the Vehicle Daily Vehicle Inspection Form is included in Section XI.G A. SNEMT APPLICATION FORM B. SNEMT CLIENT RELEASE FORM/SNEMT PROGRAM WAIVER FORM C. USER FEE WAIVER FORM X. XXXXX INSTRUCTIONS AND CLIENT GUIDELINES E. CLIENT COMPLAINT FORM F. INCIDENT REPORT FORM G. VEHICLE DAILY INSPECTION FORM H. VEHICLE INSPECTION FORM I. INVOICE TEMPLATE J. MONTHLY PERFORMANCE REPORT K. SAMPLE DEMOGRAPHIC REPORT {CONTRACTOR LETTERHEAD} DocuSign Envelope ID: E698D8F8-A9B3-46FA-8AD3-BAC2DD2BC10F A. SAMPLE Last Name: First Name: Date: Date of Birth: Age: Male: Female: Address: Apartment/Unit #: City: Zip Code: Home Phone: ( ) Cell: ( ) you YesCLIENT APPLICATION 1. Have ever utilized OCTA ACCESS or any other specialized transportation No Yes 2. Do you have any physical or functional limitations? No If yes, please describe: 3. Do you require a mobility device or special equipment for transport? Yes No Please check all that apply: Cane Xxxxxx Wheelchair Scooter Oxygen Other If yes, are you able to enter/exit the vehicle without your mobility device? Yes No Are you able to transfer from a wheelchair to seat with/without assistance? Yes No Will a Yes Yes 4. personal care attendant or assistant be traveling with you? No 5. Do you require door-to-door assistance? Yes No If yes, please describe reasons why: 6. Please list your primary doctor(s) name & address: 7. How often do you anticipate needing to use the transportation service? Weekly Monthly Other 8. Emergency Contact Name: Emergency Contact Relationship: Phone #: 9. How do you get to your medical appointments now? Yes 10. Do you own a vehicle and are you able to drive? No How did you hear about the program? White Other Ethnic background: Asian Black Hispanic Native American Annual Income per individual: • • Referrals to alternative transportation provided: • Reason referred to OoA I&A: • Need for follow-up contact: • Annual Income: At or below AMI Above AMI • Financial Hardship waiver issued: