DISABILITY INDICATOR FORM
Important Information and Instructions
You are required to complete this form if you want your police department, fire department, or other emergency agency to know about you when you call 9-1-1 in an emergency.
*PLEASE NOTE:IT IS IMPORTANT TO SUBMIT A NEW DISABILITY INDICATOR FORM UPON CHANGE OF SERVICE PROVIDER, TELEPHONE NUMBER, OR ADDRESS.*
When your 9-1-1 call is answered at your local Public Safety Answering Point, the 9-1-1 system automatically displays your name, address and telephone number on the dispatcher’s screen.
At your request, codes will be displayed on the dispatcher’s screen that will identify the disability indicators that have been reported for you or someone living with you at your address. These codes will help the dispatcher at the 9-1-1 Public Safety Answering Point to communicate with the caller and provide useful information to your responding public safety agency.
The information is confidential and will only appear at the dispatcher’s location when a 9-1-1 call originates from your address.
The information you provide for input to the 9-1-1 system will remain until you request a change or make a request to have it removed. It is your responsibility to notify your 9-1-1 Municipal Coordinator when there is a change in the information described on this form. When there is a change, complete another form and send it to your 9-1-1 Municipal Coordinator.
If the disability indicator form is not completed properly, the information will not be entered into the 9-1-1 system.
When filling out the form, be sure to:
Give your telephone number, name, and address
Check the box or boxes
Sign and date the form
Return the form to your 9-1-1 Municipal Coordinator at the below address for processing.
Any questions should be referred to your 9-1-1 Municipal Coordinator at:
Tolland 9-1-1 Coordinator
241 West Granville Rd
Tolland, MA 01034
RETAIN ORIGINAL FOR YOUR RECORDS All forms must be signed or it will be returned.
9-1-1 Disability Indicator Form-Individual Record
The filing of this document with your 9-1-1 Municipal Coordinator will alert public safety officials that an individual residing at your address communicates over the phone by a TTY and/or has a disability that may hinder evacuation or transport. This information is confidential and will ONLY appear at the dispatcher’s location when a 9-1-1 call originates from your address and is over a land line.
Telephone Number: Area code (_____) _____________________________ Voice TTY Telephone Service Provider_______________________________________ Name:________________________________________________________ Address:_______________________________________________________
Town & Zip code:________________________________________________
Please check approved designations for inclusion in the 9-1-1 Database to assist public safety dispatchers in responding to an emergency at your address: Any changes should be communicated to your 9-1-1 Municipal Coordinator promptly.
Check all that apply to indicate that someone at the address:
- “LSS” Life Support System: has equipment required to sustain their life. “MI” Mobility Impaired: is bedridden, wheelchair user or has another mobility impairment.
- “B” Blind: is legally blind.
- “DHH” Deaf or Hard of Hearing: is deaf or hard of hearing.
- “TTY”: communication via the phone may be by TTY.
- “SI” Speech Impaired: has a speech impairment.
- “CI” Cognitively Impaired: is cognitively impaired.
- PLEASE REMOVE any designation presently on file.
- PLEASE CHANGE existing designators to those shown above.
NOTICE: By initiating this document I understand that I am responsible for notifying my 9-1-1 Municipal Coordinator of any changes with regard to the status of the above disability indicator(s). I further agree, I will indemnify, defend and hold the State 911 Department, Verizon, my public safety dispatch location and municipality harmless from and against any claims, suits and proceedings (including attorney fees associated therewith) resulting from or arising out of the initial provision or updating of this information. I understand this information will remain as part of my 9-1-1 record until such time as I notify my 9-1-1 Municipal Coordinator to changing or delete the same. Signed
________________________________(Customer) DATE:________________________ Signed: ________________________________(Municipal Coordinator) DATE:________
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