Harvard Police Department 40 Ayer Road Harvard, MA 01451 (978) 456-1212 Fax: (978) 456-8313 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. As Enhanced 9-1-1 service is established in your municipality, it will display your name, address and telephone number on a screen at our local 9-1-1 answering point when your call to 9-1-1 is answered. By your request, codes will be displayed on the screen that will identify the disability indicators that have been reported for you or someone living in your home. Those codes will help the 9-1-1 answering point communicate with the caller and provide useful information to your responding public safety agencies. This 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 system will stay there until you request it be changed or 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 this form is not completed properly, the information will not be entered into the Enhanced 9-1-1 system. When filling out this form, be sure to: 1. Give your telephone number, name, and address. 2. Check the box or boxes which apply to you or someone living in your home. 3. Sign and date the form. The original and first copy of the triplicate form should be mailed to your 9-1-1 Municipal Coordinator at the address listed below. The final copy and this page should be retained for your records and information. If you need further assistance, please call you 0-1-1 Municipal Coordinator, whose number is also listed below. MAIL ORIGINAL AND FIRST COPY TO: 9-1-1 Municipal Coordinator Harvard Police Department 13 Ayer Road Harvard, MA 01451 Telephone Number: (978) 456-1212 (business only) ENHANCED 9-1-1 DISABILITY INDICATOR INFORMATION - INDIVIDUAL RECORD (Please Follow Attached Instructions) The filling 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 at your address. RECORD INFORMATION: Telephone Number ( ) - [ ] Voice [ ] TTY Name: _____________________________________________________________ Address: _____________________________________________________________ Town/City/Zip: _____________________________________________________________ The following are approved designations for inclusion in the E-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. [ ] "L.S.S." Life Support System - alerts the Public Safety Dispatcher that someone at that address is linked to equipment required to sustain their life. [ ] "M.I." Mobility Impaired - alerts the Public Safety Dispatcher that someone at that address is bedridden, uses a wheelchair or has another mobility impairment. [ ] "B." Blind - alerts the Public Safety Dispatcher that someone at that address is legally blind. [ ] "D.H.H" Deaf & Hard of Hearing - alerts the Public Safety Dispatcher that someone at that address is deaf or hard of hearing. [ ] "T.T.Y." Teletypewriter - alerts the Public Safety Dispatcher that communication via the telephone with someone at this address may be by TTY. [ ] "S.I." Speech Impaired - alerts the Public Safety Dispatcher that someone at that address is speech impaired. [ ] "D.D." Developmentally Disabled - alerts the Public Safety Dispatcher that someone at that address has some degree of cognitive disability. [ ] Please Remove any designation presently being displayed. [ ] Please Change any 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 Statewide Emergency Telecommunications Board (SETB), Bell Atlantic, my Public Safety Dispatch location and municipality harmless from and against any claims, suits, and proceedings (including attorneys 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 change or delete same. Signed: ________________________________________ Date: ___________