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______________________________
Last Name, First Name of Individual
______________________________
Date Form was Submitted
PREMISE ALERT SYSTEM REQUEST FORM
PERSON-SPECIFIC INFORMATION FOR FIRST
RESPONDERS
Individual’s Name and Date of Birth:
____________________________________________________
Address__________________________________________________________________________________
_________________________________________________________________________________________
County: ____________________________Township/Borough/Municipality:________________________
Individual’s Current Physical Description:
___Male
___Female
Attach recent
Height:
Weight:
photo here
____________
____________
Eye color:
Hair color:
____________ ____________
Scars or other identifying
marks:
_______________________________________________________________________________________
_______________________________________________________________________________________
Relevant Medical Conditions:
* HIV/AIDS IS NOT CONSIDERED A RELEVANT MEDICAL CONDITION FOR PURPOSES
OF THIS FORM AND THE PREMISE ALERT SYSTEM AND PROGRAM. UNDER NO CIRCUMSTANCES SHOULD INFORMATION RELATED TO AN INDIVIDUAL’S
HIV/AIDS STATUS BE DISCLOSED ON THIS FORM BY ANYONE.
___Blind ___Deaf
___ Non-Verbal ___Physical Disability ___Developmental Disability
___Mental Retardation ___Autism ___Mental Health Challenges
___Diabetes
___ Prone to Seizures ___Alzheimer’s Disease
___Dementia ___ Acquired Brain Injury
___Other Relevant Medical Conditions,
area for further explanation: _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Prescription Medications
needed:
_______________________________________________________________________________________
_______________________________________________________________________________________
Sensory or dietary issues, if any:
_______________________________________________________________________________________
_______________________________________________________________________________________
Additional information
First Responders may need:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Does the Individual live alone? ___________
Is he/she likely to wander off? _____________________
Location of bedroom or likely place to find the Individual in the household/residence at night:
_______________________________________________________________________________________
EMERGENCY CONTACT INFORMATION
Name of Emergency Contact (Parents/Guardians, Head of Household/Residence,
or Care Providers):
_______________________________________________________________________________________
Emergency Contact’s Address:
_______________________________________________________________________________________
_______________________________________________________________________________________
County: _________________________________________________________
Township/Borough/Municipality: ___________________________________
Emergency Contact’s Phone Numbers:
Home: ___________________________________ Work: _____________________________
Cell Phone: _______________________________ Pager: _____________________________
TTD/TTY: __________________________________________
Name of Alternative Emergency Contact: _________________________________________
Home: ___________________________________ Work: _____________________________
Cell Phone: _______________________________ Pager: _____________________________
TTD/TTY: __________________________________________
INFORMATION SPECIFIC TO THE INDIVIDUAL
Favorite
attractions or locations where the Individual may be found:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Atypical behaviors or characteristics of the Individual that may attract attention of Responders:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Individual’s favorite toys, objects, discussion topics, likes, or dislikes:
_______________________________________________________________________________________
_______________________________________________________________________________________
De-escalation techniques
or approach most likely to calm or attract the Individual:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Method of Preferred Communication. (If nonverbal: Sign language, picture boards, written words, etc.):
_______________________________________________________________________________________
Identification
Information. ( i.e. Does the Individual carry or wear jewelry, tags, ID card, medical alert bracelets, etc.?):
_______________________________________________________________________________________
IMPORTANT: Please review the following before completing, signing, and/or submitting this Premise Alert System
Form
If you choose to complete the Premise Alert System Form, the Form and information may be submitted and added to
the Local, City, County, or State Police dispatch systems for Emergency Operations. The purpose is to ensure that 911-Dispatchers
and Emergency Response Personnel are aware, in advance, of any information you believe they would need to know about people
with disabilities or health challenges in your household in the event of an emergency.
Responding to this form is voluntary.
This form may be filled out by the individual living with the specified health challenge or disability, their parent/guardian
(in the case of a minor), current Foster Family, Legal Representative or Legal Guardian. If an Individual or their Representative
chooses to use this form, they must provide their signature on the last page. (The signature of the person completing
this form is required to process the information contained on the form.) In addition, this information may be removed
from files periodically. Therefore, it is recommended that Individuals or their Representatives update and submit this form
every year to ensure that files are kept updated and accurate.
Please be aware: The information provided
on this form may assist Police, Fire, or Emergency Response Personnel, when they are responding to an emergency or other call
from your home, for purposes of identifying and/or assisting you or another Individual in your household who is living with
a disability or health challenge.
* The name of the Individual described on this form may be left off for reasons
of privacy or confidentiality. However, in situations involving group homes, foster-care homes, or supportive living
arrangements, one may simply enter the first name of the Individual to protect confidentiality. (That will not affect
the acceptance or further processing of the information on this form.)
Required Acknowledgment and Signature/s
of Individual/s Completing and Submitting this Premise Alert Form:
By completing this Premise Alert System Form, I acknowledge
that the information provided above was given and submitted voluntarily and accurately for the sole purpose of assisting Police
, Fire, and Emergency Response Departments, to more effectively respond to a potential emergency in or near my household.
I, therefore, authorize the use of this information for those purposes and to the maximum extent that I am empowered to do
so, waive any legal or equitable claim which I, or ______________________________ (the Individual’s name), or
any of our representatives, descendents, or successors, might otherwise have arising from or related to the use of the information
provided herein. I also understand that providing this information does not entitle me or anyone in my household to
preferential treatment, nor will it result in a more timely response by emergency response personnel. Completion and
submission of this form is simply an attempt to provide emergency response personnel with information, which may be helpful
when providing services to residents or occupants of my home.
____________________________________________________________
_____________
Name/ Relationship
Date
____________________________________________________________
_____________
Name/ Relationship
Date
The Premise Alert System Form is compatible with:
~ The Pennsylvania 911 Emergency Number Program,
~ The Pennsylvania State Police Central Dispatch System, and
~ The Philadelphia Central Dispatch System.
PLEASE NOTE: The Premise Alert System Form is a collaboration between Chief Kevin McCarthy, Susan F. Rzucidlo,
Law Enforcement Entities, Disability Advocates, Parent Volunteers, Educators, State & County Officials, and other interested
parties. It is owned by SPEAK Unlimited, Inc. and is protected by copyright laws. PERMISSIONS: You are permitted and
encouraged to reproduce and distribute this material in hardcopy or electronic form provided that you do NOT alter the wording
in any way, you do not charge a fee beyond the cost of reproduction, you give credit to the original authors, and receive
written permission and approval from Chief Kevin McCarthy or Susan F. Rzucidlo if alterations or changes are being recommended
for incorporation. More information on the Premise Alert System and additional resources can be found at www.papremisealert.com
or by e-mailing srz@dol.net . © 2004-7.
3/07
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