DEPARTMENT OF PUBLIC SAFETY HELP DESK FORM

2. Fill Out This Form & Take To Your Local Police Department
4. **Last Name, First Name of Individual*
5. Date Form was Submitted
7. PREMISE ALERT REQUEST FORM PERSON SPECIFIC INFORMATION FOR FIRST RESPONDERS
9. Individual’s Name
10. Date of Birth
12. Address:
14. County:
15. Township/Borough/Municipality:
17. Individual’s Current Physical Description:
19. Male/Female

    1. Male
    2. Female
20. Height:
21. Weight:
23. Eye color:
24. Hair color:
26. Scars or other identifying marks
28. Relevant Medical Conditions:

    1. Blind
    2. Deaf
    3. Non-Verbal
    4. Physical Disability
    5. Developmental Disability
    6. Intellectual Disability
    7. Autism
    8. Mental Health Challenges
    9. Diabetes
    10. Prone to Seizures
    11. Alzheimer’s Disease
    12. Dementia
    13. Acquired Brain Injury
29. Other Relevant Medical Conditions, area for further explanation:
31. 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 INDIVIDUALS HIV/AIDS STATUS BE DISCLOSED ON THIS FORM BY ANYONE. * 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.)
33. Prescription Medications needed:
34. Sensory or dietary issues, if any:
36. Additional information First Responders may need:
38. Does the Individual live alone?
39. Is he/she likely to wander off?
41. Location of bedroom or likely place to find them in the household/residence at night:
43. EMERGENCY CONTACT INFORMATION
45. Name of Emergency Contact (Parents/Guardians, Head of Household/Residence, or Care Providers):
47. Emergency Contact’s Address:
49. County:
50. Township/Borough/Municipality:
52. Emergency Contact’s Phone Numbers:
54. Home:
55. Work:
56. Cell Phone:
58. Name of Alternative Emergency Contact:
60. Home:
61. Work:
62. Cell Phone:
64. INFORMATION SPECIFIC TO THE INDIVIDUAL
66. Favorite attractions or locations where the individual may be found:
68. Atypical behaviors or characteristics of the Individual that may attract the attention of Responders:
70. Individual’s favorite toys, objects, discussion topics, likes, or dislikes:
72. Method of Preferred Communication. (If nonverbal: Sign language, picture boards, written words, etc.):
74. Identification Information. ( i.e. Does the individual carry or wear jewelry, tags, ID card, medical alert bracelets, etc.?):
76. IMPORTANT: Please review the following before completing, signing, and/or submitting this Premise Alert Form If you choose to respond, the information may be submitted and added to the local, city, county, or state police dispatch systems for Emergency Operations.
78. 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), assigned caregiver, or recognized representative. 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.
80. 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.
82. Required Acknowledgment and Signature/s of Individual/s Completing and Submitting this Premise Alert Form:
84. By completing the Premise Alert Form, I acknowledge that the information provided herein is accurate and was submitted voluntarily for the sole purpose of assisting Police, Fire, and Emergency Response Departments in more effectively responding 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 claim in law and/or equity against any of the above mentioned responder(s) which I, or
86. the individual’s name
88. or any of our representatives, descendents, or successors, might otherwise have arising from or related to the use or existence of the information provided herein. I understand that providing this information on the Premise Alert Form does not entitle me or anyone in my household, including
90. the individual’s name
92. to preferential treatment, including a more timely response by emergency response personnel. I also understand and agree that this information may be considered, only if the circumstances and exigencies confronting the police or other emergency responders permit. I also understand that if the information provided on the Premise Alert Form is considered, it may be considered along with all other relevant sources of information, and subject to proper police and emergency response procedures, when police, fire department or other emergency response personnel are responding to the residence of the individual for whom this form is being completed. Completion and submission of this form is simply an attempt to provide emergency response personnel with information that may be helpful when providing services to residents or occupants of my home, in or near my household.
94. I hereby verify that the representations made herein are true and correct to the best of my knowledge, information and belief. I acknowledge that written false statements made herein are punishable pursuant to Title 18 Pa.C.S. §4904(b) as a misdemeanor of the third degree.
96. Name/ Relationship
97. Date
99. Name/ Relationship
100. Date
102. OFFICIAL USE ONLY
104. Police Intake Signature/Date
105. Purge Date
107. Dispatch Intake Signature/Date
109. This form is compatible with all Pennsylvania Emergency Dispatch Systems.

111. 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 .

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