9-1-1 Disability Indicator Form


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/OR 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.

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 9-1-1 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.

Mail to: Lt. Robert Shannon, Norfolk Police Dept., 14 Sharon Ave., Norfolk, MA 02056