Village of Tinley Park Emergency 911 Center Premise Alert Form

Village of Tinley Park Emergency 911 Center Premise Alert Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number of the resident.
Name of Resident (If different than patient)
Location of bedroom or likely place to find person
Is he/she likely to wander off?*

YesNo
Known places person will frequent:
Has the person ever been known to become combative?*

YesNo
Does the person live alone?*

yesno
Emergency Contact Name*
Emergency Phone*
Does Someone Have a Spare Key or Door Code?*
Key Holder's Name*
Key Holder's Phone Number
Location of Spare Key or Code to Gain Access
Do you have a Lockbox?*

YesNo
Where is the Lockbox located?
What is the code for the Lockbox?
Name of Doctor
Doctor Phone Number
Hospital Preference*
List of Medications*
List of Allergies Including Allergies to Medications
Where Can We Locate a List of Meds? (i.e. refrigerator, cabinet door, etc.)*
DNR Form?*

YesNo
Location of DRN? (If Applicable)
Power Of Attorney

First NameLast Name
Power of Attorney's Phone Number
Types of Special Needs

Check all that Apply
Breathing Problems

Chronic Obstructive Pulmonary DiseaseAsthmaTuberculosisTracheostomyApnea MonitorCystic FibrosisOther
Heart Problems

Congestive Heart FailureCardiacPacemaker/DefibrillatorOther
Mental Disability

DementiaAlzheimerSchizophreniaBi-PolarDown's SyndromeOther
Diabetic

YesNo
Uses Insulin Pump?*

YesNoOther
Cancer

Current diagnosesRemissionSurvivorOther
Others:

AmputeeParaplegicQuadriplegicStrokeAutisticPhysical/Mental HandicapParkinson's DiseaseHypertensionArthritisObesityCommunicable Disease(s)Blood DisorderDeaf/Hearing Hearing LossBlindnessMute/AphasicNon-VerbalAcquired Brain InjuryOther
Mobility Aids/Medical Equipment

Uses a WalkerUses a WheelchairBedriddenOxygen at HomeVentilator at HomeHeart Blood Pump (LVAD)Other
Any other Special Needs (Please be Specific)
Any important health related information.
Village of Tinley Park Emergency 911 Center Premise Alert Form
I understand the information given above is intended to offer guidance and provide assistance to responders in aiding those people with special needs or disabilities in the performance of their duties. This information will be kept on file for a period of 2 years. We will contact you at that time to ensure that all above information is still correct. If the information is not confirmed at that time, the information will be removed from this database. It shall be the responsibility of the undersigned to notify the Tinley Park 911 Command Center in writing of any changes to this information as soon as those changes are known. The information entered into the Premise Alert Program (PAP) database shall remain confidential. This information will be relayed to responding public safety personnel via two-way radio, phone, computer, or any means available. The undersigned hereby verifies the above person has a physical or mental impairment, or has or is at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also requires health and related services of a type or amount beyond that required by individuals generally. The undersigned is the above named individual, a family member, friend, caregiver, or medical personnel familiar with the individual. By signing, I certify I have read and understand this form in its entirety and hereby give permission to Tinley Park 911 Command Center to enter this information into the Premise Alert Program (PAP) database.
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Email Address
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Type of Form

NewRevised
Date

MonthDayYear
Date
Signature*

Clear
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Village of Tinley Park Emergency 911 Center Premise Alert Form

Types of Special Needs

Village of Tinley Park Emergency 911 Center Premise Alert Form