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DISABILITY INDICATOR FORM for LANDLINE, WIRELESS, AND VoIP CONSUMERS 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 from your landline VoIP and/or wireless device. *PLEASE NOTE: IT IS IMPORTANT THAT YOU SUBMIT A NEW DISABILITY INDICATOR FORM UPON CHANGE OF SERVICE PROVIDER, TELEPHONE NUMBER, OR ADDRESS TO KEEP ALL INFORMATION ACCURATE AND UP TO DATE.* Upon submission of this completed form, when 9-1-1 is dialed from your landline or wireless device, an indicator will be displayed on the dispatcher’s 9-1-1 screen that will identify the disability indicator(s) that you have selected. This indicator(s) will be visible to the 9-1-1 dispatcher at the call center only when 9-1-1 is dialed from the number(s) listed below. The 9-1-1 dispatcher will then share this information with the first responders (Police, Fire, & EMS). The information provided on this form is confidential and will only be available to the dispatcher when a 9-1-1 call originates from the phone number provided on the form below. The disability indicator information will remain in the 9-1-1 system until you submit an updated form to request a change or removal. It is your responsibility to complete another form and resubmit it to your Municipal Coordinator when there is a change in the information described on this form. 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 type or write legibly in blue or black ink and: 1 Give your telephone number, full name, and home address. 2 Check the necessary box or boxes. 3 Sign and date the form. 4 Submit the form to your 9-1-1 Municipal Coordinator for processing ATTN 9-1-1 MUNICIPAL COORDINATORS ONLY: RETAIN ORIGINAL FOR YOUR RECORDS. Form must be signed by both parties or it will be returned. Once signed by both the consumer and the Municipal Coordinator, Municipal Coordinator should scan and email the completed form to [EMAIL REDACTED]. If you have any questions regarding the contact information for your designated Municipal Coordinator, please email [EMAIL REDACTED]. ---PAGE BREAK--- 9-1-1 Disability Indicator Form LANDLINE, WIRELESS & VoIP - Individual Record The filing of this document will alert public safety officials that an individual with the calling phone number (landline and/or wireless) has a disability that may hinder evacuation or transport. This information is confidential and will ONLY appear on the dispatcher’s NG9-1-1 screen when a 9-1-1 call originates from the phone number(s) provided below. *PLEASE NOTE: IT IS IMPORTANT TO SUBMIT A NEW DISABILITY INDICATOR FORM UPON CHANGE OF SERVICE PROVIDER AND ADDRESS. * 1. LANDLINE Telephone Number: ( ) 2. LANDLINE Telephone Service Provider: 3. WIRELESS Telephone Number: ( ) 4. WIRELESS Telephone Service Provider: 5. VoIP Telephone Number: ( ) _ 6. VoIP Telephone Service Provider: 7. Name: 8. Address: 9. 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 designated Municipal Coordinator 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. Blind: is legally blind. “DHH” Deaf or Hard of Hearing: is deaf or hard of hearing. “TTY”: may be communicating via 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 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, Comtech, DDTi and 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 change or delete the same. Signed: (Consumer) DATE: Signed: (Municipal Coordinator) DATE: