9-1-1 Disability Indicator Form

By submitting this completed form, you are notifying the local 9-1-1 response team that someone in your household has a disability.

When your 9-1-1 call is answered at your local Public Safety Answering Point, the 9-1-1 system automatically displays your name, address and telephone number on the dispatcher’s screen. At your request, codes will be displayed on the dispatcher’s screen that will identify the disability indicators that have been reported for you or someone living with you at your address. These codes will help the dispatcher at the 9-1-1 Public Safety Answering Point to communicate with the caller and provide useful information to your responding public safety agency.

The 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 9-1-1 system will remain until you request a change or make a request to have it 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 the disability indicator form is not completed properly, the information will not be entered into the 9-1-1 system.

Please return the completed form to the North Andover Police Department.
To fill out form go to:
http://www.mass.gov/eopss/docs/setb/disability-info-andform.pdf