Informed refusal form for NEMT riders: a record of a refused seat belt, securement, transfer, escort, or ride

Which refusals end the ride and which do not

An informed refusal form records that a rider heard what was offered and the risk, and declined anyway. The first thing a driver has to know is which refusals the ride survives. Some refusals are the rider’s own choice and the ride goes on. Others break a safety rule that the provider or the broker sets, and the van stays where it is. The guide to seat belts for NEMT riders covers state belt laws, and the guide to refusing a ride covers the legal limits. This page is the form that records the moment.

On private-pay trips the belt rule is yours to set. FTA’s ADA guidance, written for transit agencies, says a belt rule for wheelchair users is allowed only when it covers every rider. The wheelchair row needs one more distinction. A rider who will not allow the chair to be secured is making a refusal. A chair that is hard to secure is not. 49 CFR 37.165(d) bars denying a ride because the chair cannot be secured satisfactorily by the vehicle’s securement system, and DOT’s guidance asks for the driver’s best effort. A hard chair gets that effort and a note on the wheelchair securement checklist, not a form and not a refused ride.

The form

[Company name] rider refusal form

This form records what was offered and what the rider chose. It is not a release, and signing it is never a condition of getting a ride.

Part A. The trip

Part B. What the rider declined

• ☐ Seat belt (lap, shoulder, or both)
• ☐ Wheelchair securement (tiedowns)
• ☐ Moving from the wheelchair to a vehicle seat
• ☐ An escort or attendant
• ☐ A child safety seat or the adult required for a minor
• ☐ The vehicle or level of service booked
• ☐ The ride itself
• ☐ Other: ______________________

Part C. What the driver offered and explained

• ☐ Help with the buckle or a belt extender
• ☐ A different seat or a different belt position
• ☐ Securement in a different position, or a second try at the tiedowns
• ☐ A plain explanation of the risk. Words used: ______________________
• ☐ Dispatch on the phone with the rider or a family member
• ☐ The rider’s medical belt exemption is on file (attach or note the date) ☐ Not applicable

The rider’s own words, in quotes:

Part D. What happened

• ☐ The ride went ahead. The rider was belted and the chair secured, and the choice recorded above was the rider’s to make.
• ☐ The ride did not go ahead. Reason: ______________________
• Where the rider was left, and with whom: ______________________
• Broker or payer told (name, time): ______________________
• Family, facility, or case manager told (name, time): ______________________

Part E. Signatures

☐ The rider declined to sign. Driver initials: ______ Witness initials: ______

Filling it in

Fill the form in after the driver has made the offer, in the rider’s own words, with dispatch told before the van moves or leaves.

1. Offer first, record second. Some refusals come down to discomfort or a belt that will not reach. The seat belt guide lists the fixes. Start the form only after the offer has been made and turned down.
2. Use the rider’s words. “He said he would rather sit unbuckled for the short ride” tells a reviewer more than “refused belt”.
3. Explain the risk in plain terms, and no more. For a transfer, the point to make comes from the University of Michigan’s Ride Safe guide: a vehicle seat with the vehicle’s own belt is the safest place in general, and when a transfer is not practical the chair should face forward, be secured, and have a crash-tested belt on the rider. Do not frighten or pressure the rider. DOT’s guidance lets a provider give information on risks and make a recommendation, and leaves the decision with the passenger.
4. Call dispatch before the van moves or leaves. Dispatch calls the broker on a broker trip and the facility or family on a private one. Write the name and the time.
5. Tell the broker what it wants to know. Ask each broker whether a refused ride must be reported on its own form. Modivcare’s Mississippi manual, for example, lists an Incident/Accident and Injury report among the forms providers use.
6. Keep one copy with the trip record for as long as you keep that trip, and send a copy to the rider or guardian on request. The record retention schedule lists how long trip records stay.

What the form cannot do

The form records a choice. It cannot make an unsafe ride acceptable, work as a release, replace a medical exemption, or turn a rider away because of a disability.

It cannot make an unsafe ride acceptable. The first table shows the refusals where the answer is the same whatever the rider signs. The broker rules say the van does not move without belts or with an unsecured chair, and a provider may require securement under 49 CFR 37.165(c)(3).

It is not a release. FTA’s ADA guidance reads 49 CFR 37.5 to mean an agency may not require a rider with a disability to sign a liability waiver as a condition of service. The guidance is written for transit agencies, but the rule it reads also covers private companies in the business of transporting people. Some brokers do issue their own release for securement refusals, as Modivcare’s Mississippi manual does with its Securement Waiver. Use a broker’s form only for what it names, ask the broker before any ride goes ahead on it, and read how courts treat releases in liability waivers for NEMT riders.

It cannot replace a medical exemption. A rider who cannot wear a belt for medical reasons needs the paperwork their state and broker ask for before the first trip, not a form at the curb.

It cannot be used to turn a rider away because of a disability. Using a wheelchair, traveling without an attendant, or behaving in ways a disability causes is not a refusal by the rider. Conduct that is violent or seriously disruptive follows the conduct policy, and the incident goes on the incident report.

Keeping the record with the trip in HealthRide

A refusal is easier to explain when the trip record already shows what happened around it. HealthRide keeps each trip’s pickup and drop-off times and GPS-recorded miles, captures signatures on screen in the driver app, and records wait times on no-shows. Drivers and dispatch talk in team chat rather than on personal phones, so the conversation about a problem ride stays with the company.