Form 9-1-1 - Disability Indicator Form-Individual Record Page 2
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29-1-1 Disability Indicator Form-Individual Record
The filing of this document with your 9-1-1 Municipal Coordinator will alert public safety officials that
an individual residing at your address communicates over the phone by a TTY and/or has a disability
that may hinder evacuation or transport. This information is confidential and will ONLY appear at the
dispatcher’s location when a 9-1-1 call originates from your address.
*PLEASE NOTE: IT IS IMPORTANT TO SUBMIT A NEW DISABILITY INDICATOR FORM UPON
CHANGE OF SERVICE PROVIDER AND ADDRESS.*
Telephone Number: Area code (_____) _____________________________ Voice
TTY
Telephone Service Provider_______________________________________
Name:________________________________________________________
Address:_______________________________________________________
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 9-1-1 Municipal Coordinator promptly.
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.
“B” Blind: is legally blind.
“DHH” Deaf or Hard of Hearing: is deaf or hard of hearing.
“TTY”: communication via the phone may be by 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 9-1-1
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, Verizon, 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 changing or delete the same.
Signed :________________________________(Customer) DATE:________________________
Signed: ________________________________(Municipal Coordinator) DATE:______________
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