
Client
___________________________________________________________________________
Date of travel
___________________________________________________________________________
File/Locator no.
___________________________________________________________________________
Phone/E-mail
___________________________________________________________________________
Service provider (carrier)
___________________________________________________________________________
Advise carrier of the nature of the person's disability
Obtain written confirmation of services to be provided
| Accessible Services for Persons with Disabilities | Date Requested | Date Carrier Notified | Date Carrier Confirmed |
|---|---|---|---|
|
1) Information in multiple formats on itineraryrates disability-related services: ___________________________________________________ other: ___________________________________________________ Multiple formats e-mail braille text only |
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2) Seating that meets the person's needs (except in emergency exit rows) moveable aisle arm rest ___________________________________________________ |
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3) Attendant(s)* ___________________________________________________ |
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| 4) Carriage of a mobility aid* Type: ___________________________________________________ Dimensions: ___________________________________________________ Type of batteries: ___________________________________________________ Special tools/instructions needed to disassemble/assemble: ___________________________________________________ Tools/instructions to be provided by carrier traveller |
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| 5) Use of gaseous oxygen or portable oxygen concentrator on board and/or in terminals* carrier-provided (fees may be applicable) passenger-provided assistance to/from washroom with oxygen Is oxygen needed between flights/travel segments? |
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| 6) Accessible ground transportation to/from terminal taxi shuttle city bus between terminals other: ___________________________________________________ Are advance reservations for accessible ground transportation required? yesno |
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7) "Unaccompanied-passenger" services (a higher level of assistance for individuals such as persons who have cognitive or intellectual disabilities) ___________________________________________________ |
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| 8) Assistance with registration at check-in counter? yesno |
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| 9) On departure, assistance to transfer from a passenger mobility aid* at registration counter at departure gate between a mobility aid and a passenger seat at aircraft/vehicle door On arrival, assistance to transfer to a passenger mobility aid between a passenger seat and a mobility aidat aircraft/vehicle door at arrival gate at baggage carrousel* Request electric cart or carrier-provided wheelchair? |
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| 10) Assistance to get to the boarding gate/area? yesno If yes, specify: ___________________________________________________ Assistance with short distances and stairs? yesno |
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11) Assistance to board/deboard? yesno ___________________________________________________ |
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| 12) Assistance to store and retrieve carry-on baggage? yesno |
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| 13) Is an on-board wheelchair available? yesno |
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| 14) Is a tie-down available? yesno |
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15) Meal-related services provided on-board: dietary requirements related to the person's disabilityopening packages identifying items cutting large portions |
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| 16) Assistance to move to/from the onboard washroom (except by carrying)? yesno |
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17) Assistance to get to a representative of another carrier in the same terminal? yesno If yes, specify:___________________________________________________ |
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| 18) Assistance to retrieve checked baggage? yesno |
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| 19) Assistance to get to the general public area to a service animal relief area |
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| 20) Carriage — free of charge — of a trained, certified and harnessed service animal at the person's seat Size (height, width, length in a standing position): ___________________________________________________ Verify space for service animal at the person's seat |
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| 21) Carriage — free of charge — of the person's mobility aid (not counting towards checked baggage allowance) |
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| 22) Carrier to issue a ticket to notify connecting carrier(s) of services to be provided |
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23) Allergies ___________________________________________________ |
*There may be conditions or restrictions applicable to this service that should be discussed with the person with a disability.
For more information about the Agency, please contact:
Canadian Transportation Agency
Ottawa, ON K1A 0N9
Telephone: 1-888-222-2592
TTY: 1-800-669-5575
Facsimile: 819-997-6727
E-mail: info@otc-cta.gc.ca
Web site: www.otc.gc.ca
Available in multiple formats.