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Disability Indicator Form

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.

You may fill out the electronic form below, or fill out the printable form and bring it to the Holbrook Police Station.

Printable Disability Indicator Form

"*" indicates required fields

9-1-1 Disability Indicator Form for LANDLINE CUSTOMERS ONLY-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.
Name*
Address*

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:*

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, GDIT, 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.
Consent*