Checklist for Disabled and Less Mobile Passengers

 

We want everyone to enjoy completely successful travel arrangements.  We strongly recommend that this checklist be completed before making a booking if you have a disability or a medical condition requiring special travel, accommodation or dietary arrangements.  The form should also be used to give information regarding specific needs for equipment and / or medication you may have.  It can be completed by you or the travel agent.  The questions are not meant to be intrusive - the information you provide will be treated confidentially and will be used only to check that the accommodation, transport and facilities in the destination are right for you.  It all helps to ensure you receive a quality service tailored to your particular needs.

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Please circle the Yes or No options below – the instructions make it clear which sections you don’t need to complete.

Text Box: A. Your travel details
 

 

Much of the information below will be on your travel documentation. Your travel agent or Tour Operator can provide this for you.

 

Lead name:

(this is name of the person making the booking)

 

Full name of customer with special requirements:

(fill this in if different from the name above)

 

Your phone number and e-mail address:

 

Name of your Tour Operator:

Holiday/travel booking reference:

 

Your departure date:                                                        

Outbound flight number:

Your return date:

Return flight number:                 

 Name of your Travel Agent:





 

Text Box: B.   General information about you
 

1.           How would you describe your disability?

            (If you feel it may be helpful, please give us the medical term for your disability)

 

 

Text Box: C. Getting around 
 

1.           Do you have any kind of mobility difficulty or a disability which makes it difficult for you to get around?                                                   

                                                                                                                   Yes / No

          If No please go to Section D below.

 

          If Yes please give details…

For example, although you may not need assistance all the time some distances at the airport terminal can be long – between the airline check-in desk and the departure gate, say, or you may be a slow walker.

 

 

2.           Can you walk or travel on your own without assistance in an unfamiliar place?                                                                            Yes / No

For example, you may be blind or visually impaired, or become confused when in unfamiliar places such as airports

 

3.           Do you use a wheelchair?                                                            Yes / No

          If No, please go to question 5 below.                                                                                                                                                                     

    If Yes, will you be taking your own wheelchair?                            Yes / No

    If No, please go to question 4 below.

 

          3 (a) If Yes, is it battery operated?                                               Yes / No

 

          3 (b)  If Yes, is it:          i)  Dry Cell                                                            Yes / No

                                      ii) Wet Cell                                                           Yes / No

 

          3 (c)  If Yes, does it fold up?                                                                   Yes / No

 

3 (d)  If Yes, what are the dimensions and weight of your wheelchair?

 

Open:    Width….…........ins.   Height ………. ins.           Depth.……………ins.

 

Closed: Width …………ins.     Height ……..…ins.           Depth…………….ins.

 

Weight:

 

4.           Do you need to borrow a wheelchair to / from the aircraft?

            Please ask your travel company for details immediately about how they can help

 

Yes / No

 

5.           Can you walk up/down the aircraft steps without assistance?

            Please be aware, these steps can be steep with narrow treads

Yes / No

 

 

6.           Do you require a wheelchair to visit the WC on board the aircraft?

Yes / No

 

 

7.           If there is a transfer coach from the airport to the hotel provided as part of your travel arrangements, can you board and leave a standard coach without additional assistance other than from any companion you may be travelling with?

Some buses and coaches may have steep steps

                                                                                                                      Yes / No

 

 

8.           If there is no transfer coach provided as part of your arrangements, do you need a taxi transfer from the airport to your accommodation and return?

There may be a charge for this. Please ask your travel company for details

Yes/ No

 

 

Text Box: D.   Getting access to information
 

1.           Do you have a disability that would make it difficult to see or hear or understand important information, or communicate easily with people providing important or emergency information?

 

Yes / No

 

          If Yes, in what alternative format would you prefer to receive printed or visual information? For example, some routine flight departure information may not be announced over loudspeakers and may only appear on a television screen; and on some aeroplanes the in-flight safety card or demonstration may not be accompanied by full spoken explanation.

 

 

 

 

 

Text Box: E.  Travelling on an Aircraft or Coach

 

1.    Is it best for you to sit near to the WC?                                        Yes / No

 

 

2.    Is it best for you to have an aisle seat?                                       Yes / No

          If yes, why?

 

 

3.    Do you prefer a ‘no smoking’ seat?                                              Yes / No

 

 

4.    Will you be taking medication during the journey?                             Yes / No

If Yes, please provide details...

 

 

5.    Are you taking any medical equipment?                                               Yes / No

If Yes, please provide details...

 

 

6.    Are you asthmatic or do you have other breathing difficulties?

                                                                                                                    Yes / No

If Yes, please provide details...

 

 

7.    Are you likely to require supplementary oxygen?                    Yes / No

There will almost certainly be a charge for supplementary oxygen

 

 

8.    Are you travelling with any kind of assistance dog?                          Yes / No

      You must make sure that the dog has been micro-chipped,

      processed and immunised against rabies in accordance

      with the Pet Passport Scheme (Check with the Guide Dogs

      for the Blind Association, telephone: 01189 835 555)

 

Text Box: F.    Your accommodation
 

1.    Can you walk up/down stairs unaided?

It is important to know how many steps you can cope with unaided and whether this applies all the time.

 

a) all / most of the time          b) some of the time      c) occasionally

 

 

 

2.    Would you prefer a ground floor room?

For example: if the property has no lift, would you be able to cope with a room on the first floor.

                                                                                                                   Yes / No

 

 

3.    Would you prefer a room near the lift?                                        Yes / No

 

4.    What special facilities do you require in your room?

Grab Rails

 

Fridge for Medication

 

TV with Teletext

 

Level entry shower

 

Accessible Telephone

 

Adjustable bed height

 

Vibrating Pads for Alarm/alarm clock

 

Wash basin with lever taps

 

 

Other [Please specify]

 

         

 

 

Text Box: G.  Meals
 
 

 

1.    Do you have a special dietary requirement?                              Yes / No

If Yes, please give details...

 


 

Important customer information

 

This information will be passed on to your travel suppliers, who will do their best to meet your needs.  However it is very important to remember that:

 

·        Meeting your needs cannot always be guaranteed.  For example, aeroplanes, coaches and other elements of your travel may need to be substituted without prior notification due to unforeseen circumstances (i.e.  breakdown, cancellation or non-availability of accommodation).

·        Your travel insurance policy should adequately cover any pre-existing medical conditions and cover any expensive equipment you may be taking.

·        Any change in your requirements may affect the suitability of the travel arrangements you have made.  It is important to let your travel agent or tour operator know of any changes immediately.

·        It is important read the ‘Guidance for disabled and less mobile passengers’ produced by the UK’s Disabled Persons Transport Advisory Committee (DPTAC) www.dptac.gov.uk/pubs/aviation/access/index.htm or email: dptac@dft.gov.uk, or phone: 020 7944 8011.

·        Airlines use an internationally recognised coding system to identify the level of assistance they need to provide to individuals.  A copy of that list is included in this checklist.

 

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I confirm that the information given on this form is correct and understand that there is no guarantee that these needs will be met. I also understand that this information will be passed on to those people responsible for supplying all the arrangements for my travel, but that it will not be communicated to any party which is not responsible for the supply of any of my travel arrangements.

 

 

Customer signature…………………………………           Date……………………..

 

If you are answering the above questions on behalf of a disabled person please sign below to confirm that this information is accurate and that you have the disabled person’s permission to pass it on for the purpose of making travel arrangements.

 

 

Customer signature…………………………………           Date……………………..

Text Box: Agency Name:                                                                       Agency Stamp:
 
 
(I am over 18 years of age)

 

 

 


 

Airline categories for disabled people requiring assistance

 

MEDA                   Passenger whose mobility is impaired due to clinical cases with medical pathology in progress, being authorised to travel by medical authorities. Such a passenger usually has social coverage in relation to the illness or accident.

 

STCR                    Passenger who can only be transported on a stretcher. Such a passenger may or may not have social protection or specific insurance.

 

WCHR                   Passenger who can walk up and down stairs and move about in an aircraft cabin.  Passenger who requires a wheelchair or other means for movements between the aircraft and the terminal, in the terminal and between arrival and departure points on the city side of the terminal.

 

WCHS                   Passenger who cannot walk up or down stairs, but who can move about in an aircraft cabin.  Passenger who requires a wheelchair to move between the aircraft and the terminal, in the terminal and between arrival and departure points on the city side of the terminal.

 

WCHP*                 Passenger with a disability of the lower limbs who is unable to take care of him/herself.  Passenger who requires assistance to embark or disembark and who can move about in an aircraft cabin only with the help of an onboard wheelchair.

 

WCHC                   Passenger who is completely immobile who can move about only with the help of a wheelchair or other means and who requires assistance at all times from arrival at the airport to seating in the aircraft or, if necessary, in a special seat fitted to his/her specific needs.  The same kind of assistance is required at both ends of the journey.

 

BLIND                   Blind or visually impaired.

 

DEAF                    Passenger who is deaf or a passenger who is deaf without speech.

 

DEAF/BLIND       Passenger who is both deaf and blind, who can only move around with the help of an accompanying person

 

MAAS                   Meet and assist - all other passengers in need of special assistance.

                                                          * WCHP is not yet internationally recognised

 

 

 
If you require any further information regarding any of the above questions
please do not hesitate to call us, we shall be pleased to assist.
 

                       


MIKE COLES WORLD WIDE TRAVEL
For all your travel arrangements
Call us for
Reservations, Information, Assistance & Advice


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