BESB: How to Alert 9-1-1 to Your Special Needs

How to Alert 9-1-1 to Your Special Needs

 

You should complete this form if you want your police department, fire department, ambulance, or other emergency response agencies to know about medical conditions or disabilities when you call 9-1-1 in an emergency.

 

When you call 9-1-1 from a wireline phone, Connecticut’s 9-1-1 emergency telephone service displays your name, address, and telephone number at your local 9-1-1 answering point. (A wireline phone is a phone that has a wire from a telephone pole to your home.) Filling out this form will alert the 9-1-1 operator that you or someone else living in your household has a medical condition or disability. This information helps the 9-1-1 operator to provide appropriate emergency help.

If you want the 9-1-1 operator and emergency response staff, (that is the police department, fire department, or emergency medical staff) to know that you or someone else living in your household has a medical condition or disability, fill out this form. This information will be displayed at the 9-1-1 answering point only when you call 9-1-1.

 

This service is not available for cell or internet phones.

The information that you provide will be put into the 9-1-1 system and will stay there until you request that it be changed or removed or your account is closed. It is your responsibility to notify us when there is a change in the condition described on this form. When there is a change, send us an updated form.

 

When filling out this form, be sure to:

1. Provide your name, address, and telephone number.

2. Check the box or boxes which apply.

3. Sign and date the form,

 

Mail this form to AT&T at this address:

AT&T

Enhanced 9-1-1 DMS Group

310 Orange St., 2nd Floor

New Haven, CT 06510

(Rev. 6/2005)

 

How to Alert 9-1-1 to Your Special Needs

Telephone Number (include area code)

Name

Address

Town/City

Check all the boxes that apply.

 

____B Blind – Someone at this location is blind or visually impaired.

_____COG Cognitive Impairment – Someone at this location has a cognitive impairment.

_____H/D Hard of Hearing / Deaf – Someone at this location is hard of hearing or deaf.

_____LSS Life Support System - Someone residing at this location is physically

linked to equipment required to sustain his or her life.

_____MI Mobility Impaired - Someone residing at this location is bedridden, uses

a wheelchair, or has a mobility impairment.

_____PI Psychiatric Impairment – Someone at this location has a psychiatric impairment.

_____SI Speech Impairment – Someone at this location has a speech impairment.

_____TDD Telecommunications Device for the Deaf – Someone at this location may

be using a TDD/TTY.

 

_____Please remove any existing indicators presently being displayed.

 

_____Please change existing indicators to the ones above.

 

By completing this form, I understand that I am responsible to notify AT&T of any changes with regard to the above information. I further agree that I will indemnify, defend, and hold harmless AT&T, the State of Connecticut, the Public Safety Answering Point, and my municipality from and against any and all claims, suits, and proceedings resulting from or arising out of the provision of this information.

I understand that this information will remain as part of my 9-1-1 record until such time as I notify AT&T to either change or delete it.

 

Signature:

 

Date: 

 
 
 
 




Content Last Modified on 11/30/2007 6:04:17 PM