application for a blue badge - buckinghamshire county council€¦ · application for a blue badge...

Application for a Blue Badge Form BB1 (2016)

Overview

* Is this a new application or a renewal (please tick) A paper application takes 6 weeks to process. If the badge is required urgently it is faster to apply online, which takes 3 weeks. Apply online: www.gov.uk/apply-blue-badge You will be asked for some personal details to help us deal quickly with your application. It will also help to prevent fraud. This will include:

• Your National Insurance Number

• If you already have a Blue Badge, the number, expiry date and the name of the issuing local authority. These can all be found on the badge

You must also send us a passport style photograph signed on the reverse. This photograph will appear on the back of the badge and will not be on display when the badge is used in the vehicle. At the end of the application form, you will be notified of what you need to do next. This will include sending in proof of your address and your identity.

You will be asked some detailed questions about your walking ability to help us assess whether or not you are eligible for a Blue Badge in the area where you live. Robust procedures to ensure the protection of your data have been put in place and the system holding your information has been accredited to Restricted level – this is one of the highest privacy markings used by government. Your information will only be able to be accessed by the local authority processing your application. A limited amount of information will be accessed by enforcement officers to prevent abuse of the Blue Badge scheme.

http://www.gov.uk/apply-blue-badge

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Form BB1 (2016)

Eligibility

Reason for applying I am registered as blind (severely sight impaired)

I have either a Certificate of Vision Impairment (CVI) or a BD8 form, signed by a consultant ophthalmologist, stating that I am severely sight impaired (blind) and I wish to be registered as severely sight impaired (blind) with my local authority

I receive the Higher Rate of the Mobility Component of the Disability Living Allowance

I receive a Personal Independence Payment (PIP) as I meet a 'Moving Around' descriptor for the Mobility Component because I either cannot stand or can stand but walk no more than 50 metres. This is a score of 8 points or more.

I receive a War Pensioners' Mobility Supplement

I receive a tariff within 1-8 (inclusive) of the Armed Forces Compensation Scheme and have been assessed as having a permanent and substantial disability which causes inability to walk or very considerable difficulty in walking.

I am over the age of two and have a permanent and substantial disability which means that I am unable to walk

I am over the age of two and have a permanent and substantial disability which means that I have very considerable difficulty in walking

I drive a vehicle regularly, and have a severe disability in both arms that means I am unable to operate all or some types of parking meter

I drive a vehicle regularly, and have a severe disability in both arms that means I have considerable difficulty operating all or some types of parking meter

I am under the age of three and have a medical condition that means I must always be accompanied by bulky medical equipment

I am under the age of three and have a medical condition that means I must always be kept near a vehicle in case I need emergency medical treatment.

None of the above apply

.

Your eligibility may need to be assessed / re-assessed by our independent mobility assessor who is a fully qualified physiotherapist. Assessments take place by appointment in either High Wycombe or Aylesbury. There is currently a waiting list for assessments and this could delay an initial application. For the purposes of fraud prevention we also carry out random mobility checks on a sample of renewal applications.

Section 1 Personal Details

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Form BB1 (2016)

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Personal Details

Evidence Medical Condition

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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Personal Details

Title * Do you have a terminal illness? Yes No

We may be able to fast track your application if your illness seriously limits your mobility

* First Name

Other Names

* Surname

* Surname at Birth

* Gender Male Female

* Date of Birth (DD/MM/YYYY) ___ ___ / ___ ___ / ___ ___ ___ ___

* Town of Birth

* Country of Birth

National Insurance Number

So that we can process your application we may check the National Insurance Number you have given us with third parties in order to verify your identity. By providing the information requested you are consenting to your details being submitted to those third parties for this purpose. Driving Licence Number (If you hold a driving licence) ____________________________

Please sign the back of your photograph and securely fix it here.


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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)

Address Details

The address where you usually live. Your previous address, if different in the last three years.

* Address Line 1 * Address Line 1 Line 2 Line 2 Line 3 Line 3 *Town *Town

County County * Post Code * Post Code

Contact Details

Home Telephone Number The Email Address will be used by Buckinghamshire County Council to send you a confirmation when the application is submitted

Mobile Telephone Number

Email Address

How would you prefer to be contacted?

Mail If your application is successful then your preferred contact method may be used to send a reminder when the badge is due to expire.

Home Phone

Email

Mobile


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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)

Vehicle Details

Enter up to 3 vehicle registration numbers

Vehicle 1 Vehicle 2 Vehicle 3

Badge Details

* Have you had a badge before? Yes No

* Which local authority issued the latest badge?

What is the number on the latest badge?

What is the expiry date of the latest badge?

(DD/MM/YYYY) ___ ___ / ___ ___ / ___ ___ ___ ___

Next section

Section 2 Evidence

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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)

Proof of Address

We will need to check that your main residence is in our area. Supply a photocopy of any document selected bearing your name and address unless otherwise indicated.

* Please select one of the following

Council Tax bill bearing my name and address, dated within the last 12 months.

I do not pay Council Tax, I am over the age of 16 and give consent to the local authority to check my address on the electoral register.

I give consent to the local authority to check my personal detail on the local authority’s Council Tax database so that I do not need to submit proof of my address.

Award letter from Service Personal and Veterans Agency.

Benefit award letter from the Department for Work and Pensions.

Confirmation letter from Social Services or another local authority service that the person is resident.

Confirmation letter from the school that the child attends that school, if under 16.

Copy of a valid driving licence.

Housing benefit (or other type of benefit) award letter dated within the last 12 months.

Pensions letter from The Pensions Service.

Section 2 Evidence

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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)

Proof of Identity

To reduce the potential for fraudulent applications for a Blue Badge, we will need to check your identity. You must supply a photocopy of one of the following as proof of your identity.

* Please select one of the options below

Birth certificate/adoption certificate

Certificate of British Nationality

Civil Partnership/Dissolution cert

Passport

Identity Card for Foreign Nationals

HM Forces ID card

Marriage/Divorce Certificate

Valid driving licence

Next section

Section 3 Medical Condition

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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)

Applicants with Walking Difficulties

* Please describe any medical conditions and/or disabilities which affect your walking. If you know them, please state the medical terms for the conditions/disabilities with which you have been diagnosed.

Please describe any surgery, courses of treatment you have undergone or specialist clinics you have attended in relation to each medical condition/disability you have mentioned.

* Please state when you underwent any relevant surgery or treatment or attended specialist clinics.

Surgery Treatment or Clinic Date (DD/MM/YYYY)

___ ___ / ___ ___ / ___ ___ ___ ___

___ ___ / ___ ___ / ___ ___ ___ ___

___ ___ / ___ ___ / ___ ___ ___ ___

___ ___ / ___ ___ / ___ ___ ___ ___

___ ___ / ___ ___ / ___ ___ ___ ___

Section 3 Medical Condition

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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)


What medication do you currently take in relation to the conditions/disabilities you described above?

Medication Dosage Frequency

Please describe any pain relief you are taking in relation to the medical conditions/disabilities you mentioned above and the frequency you need it.

Next section

Section 4 Current Status

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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)


* Please tick whichever statements apply to you and provide further details in the space below if necessary.

I am awaiting surgery in relation to the conditions/disabilities described above.

I am recuperating from surgery in relation to the conditions/disabilities described above.

I am awaiting treatment in relation to the conditions/disabilities described above.

I am managing my conditions/disabilities since I have been advised they are not expected to improve any further

None of the above

Details

* Please give details of the healthcare professionals, or specialists (including your GP) who have been treating you in relation to the conditions/disabilities described above.

Name Job Title Hospital / Health Centre Phone Number

Section 4 Current Status

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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)


* Do you anticipate that you conditions/disabilities will improve in the next 3 years?

Yes No Don’t Know

If you have entered Yes above, please describe how much you expect your conditions/disabilities to improve.

* How do the conditions/disabilities you described affect your ability to walk? For example; pain when walking, shortness of breath, balance problems, use of walking aids)

Next section

Section 5 Walking Ability

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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)


* Please tick whichever of the following statements describe your general walking ability.

I am able to walk well, including recreational walks.

I am able to walk around the supermarket to do my own shopping.

I am able to walk and can use public transport for some of my local trips.

I am able to walk, but struggle with longer distances or hills.

I am able to walk, but get breathless if I walk more than a few minutes.

I am able to walk, but find it too painful to walk more than a few minutes.

I am able to walk, but use a wheelchair for longer trips outside the home.

I am able to walk around my home, but am unable to climb the stairs.

I am unable to walk at all.

Other (please describe below)

Other details about your walking disability

Section 5 Walking Ability

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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)


* Are you able to walk outside without help? * Please select the option that best describes the way you walk

Yes No Normal. No specific problems with walking

If you answered No above please describe the help you need. Adequate. For example, you walk with a slight limp

Poor. For example, you walk with a heavy limp, a stiff leg or shuffle, or have problems with balance

Extremely poor. For example, you drag your leg, stagger, swing through two crutches or need physical support

* Where in your local area, can you comfortably walk to from your home? (Please state a specific location or landmark which could be found on a map, e.g. a shop, street address or park)

Other. If none of the above describes the way you walk, please tell us in your own words about the way you walk in the space provided below:

Next section

Section 6 Walking Aids

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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)


Do you use any of the following walking aids? (Please select whichever options apply to you – you can select more than one)

1 elbow crutch 2 elbow crutches 1 walking stick 2 walking sticks Walking frame (Zimmer frame)

Rollator

Wheelchair

Powered wheelchair

Other (please describe below)

Details


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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)


* How far would you estimate you are able to walk using any walking aids, before you feel severe discomfort?

Distance _____________ Yards Metres (Please state the distance in metres or yards using whichever measure is best for you).

When answering this question please note that:

• The average adult step is just less than one metre, which is 1.1 yards or 3 feet and 4 inches.

• If you walk alongside someone and they take 100 steps you would have walked roughly 90 metres, or 100 yards.

• The average double-decker bus is about 11 metres, or 12 yards, long.

• A tennis court is about 24 metres, or 26 yards, long.

• A full size football pitch is about 100 metres, or 110 yards, long

Roughly how many minutes would you estimate it takes you to walk this distance?

Number of minutes _____________________


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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)


Are you able to continue walking after a short rest?

Yes No

If you can continue, roughly how many minutes are you able to walk for in total?

Number of Minutes _____________________ Please answer ‘Yes’ or ‘No’ to each of the following questions * Are you troubled by shortness of breath when hurrying on level ground or walking up a slight hill?

Yes No

* Do you get short of breath walking with other people of your own age on level ground?

Yes No

* Do you have to stop for breath when walking at your own pace on level ground?

Yes No

* Do you get too breathless to leave your home, or after dressing?

Yes No Next section

Section 7 Declarations

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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)

Further Information and Declarations

Is there anything else you can add that you think is relevant in support of your application for a Blue Badge?

Please read the following mandatory declarations.

• Please tick all relevant boxes to indicate that you have read, understand and agree with each declaration. • Not ticking one of these declarations may mean we are unable to issue you with a Blue Badge. • Provided fraudulent information may result in prosecution and a fine.

I confirm that, as far as I know, the details I have provided are complete and accurate. I realise that you may take action against me if I have provided false information in this application form.

I understand that I must not hold more than one valid Blue Badge at any time.

I understand that I must promptly inform any issuing authority of any changes that may affect my entitlement to a badge.

I understand that the local authority may need to contact an accredited healthcare professional for the purpose of obtaining further information in support of my application.

I confirm that the photograph I will submit with my application is a true likeness.

I understand that I may be required to undertake a mobility assessment with a healthcare professional who is independent of my existing care and treatment, in order to determine my eligibility for a Blue Badge.

I understand that, if my application is successful, I must not allow any other person to use the badge for their benefit and that I must only use the badge in accordance with the rules of the scheme as set out in the “Blue Badge scheme: rights and responsibilities in England” leaflet which will be sent to me with the badge.

I confirm that I am the applicant.

Section 7 Declarations

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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)

Further Information and Declarations

Please read and tick the following optional declarations that you consent to. Ticking these boxes will help to improve the service we can offer you.

I consent to the local authority checking any information already held by the local authority’s Social Services department on the basis that:

• It can help determine my eligibility for a Blue Badge

• It may speed up the process of my application

• It may enable a decision to be made without the need for a mobility assessment

I agree to the disclosure of the information included in this form to other council departments/service providers so that I can be informed about other council services that may be of benefit to me.

You must confirm you have read the privacy statement.

All documents relating to this application will be dealt with in line with the Data Protection Act 1998 and may be shared within the local

authority, with other local authorities, the police and parking enforcement officers to detect and prevent fraud. Any medical information that

you have supplied to support this application is deemed, under the Data Protection Act, to be “sensitive personal data” and will only be

disclosed to third parties as necessary for the operation and administration of the Blue Badge scheme, and to other government

departments or agencies, to validate proof of entitlement or as otherwise required by law.

* I confirm I have read this privacy statement Next section

Section 8 Payment

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Personal Details


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Walking Aids

Walking Ability

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Current Status

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Declarations

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Payment

Form BB1 (2016)

Paying for the badge

The cost of a blue badge is £10 Please attach a cheque for £10 made payable to ‘Buckinghamshire County Council’ with the applicant’s name clearly printed on the back. The cheque will be returned if your application is unsuccessful. Please note we cannot accept cash. Please check that you have included

A signed passport size photo, signed on the reverse

A photocopy of my proof of eligibility (where applicable) as ticked on page 1

A photocopy of my proof of address as ticked on page 5

A photocopy of my proof of identity as ticked on page 6

A cheque for £10 made payable to Buckinghamshire County Council with the applicants name clearly printed on the back Please send photocopies and not originals, as these cannot be returned.

* Signed: _________________________________________ Date: _____________________ Return your completed form to

Blue Badge Team BCC Council Offices Easton Street High Wycombe Bucks HP11 1NH Email: [email protected] Website: www.gov.uk/apply-blue-badge

application for a blue badge - buckinghamshire county council€¦ · application for a blue badge...

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