You can fill the Premise Alert Form out yourself
or
ask a friend or case manager
to help you
Some individuals who are identified as having special needs are also at a higher risk for coming in contact with police or
other first responders. You may feel uncomfortable talking with police officers or other first responders. This form
was developed to support individuals and educate first responders. The goals of this checklist are to reduce the occurrence
of unfortunate incidents and supply the police with critical information that is specific to the individual.
Filling out this form is voluntary.
You do not have to fill out this form.
No
one can force you to fill out this form.
The information
you provide will be kept confidential and will only be used in the event that you require intervention. A “premises
alert” will be attached to your home address in the 911 command center so that pertinent information will be available
to the responding officer or first responder if the need arises. Situations in which this information might be used
could include, the you are ill, lost, there is a fire at your home, or a medical emergency that requires an ambulance to be
dispatched...
This form is being provided as a service to individuals. Not all individuals
will feel the need to fill out this form. Those who need to call their police department for support or intervention
may find that having this form on file will give the responding officer some background information on the individual to interact
more successfully. It is intended to be a safety net for families and individuals.
If
you choose to fill out this form, you may mail or hand deliver it to the police station that serves your area. A case
manager or other support staff can go with you to deliver this form. If you are unsure of which police department serves
your area, contact your township or town government office and they will assist you. If you are in an area where the state
police assist your local department make a second copy for them.
Do not call 911 unless it is an emergency.
If you don’t have a current photo call ahead to the police department for an
appointment and they will take a digital photo of you to attach to the form.
If you have any
questions contact the department of Human Services in your county or a MH/MR case manager, wrap-around provider or county
social worker. They will be able to help you. This form must be renewed for accuracy each year.
This
form must be renewed annually in order for 911 to keep it in the system.
