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Personal Alert Indicator Form for People with Disabilities

Individuals Information

Individuals Name
Address
Gender
Max. file size: 128 MB.
Medical Conditions
Is the individual non-verbal
Is the Individual Impacted By Bright Lights or Loud Noises
For example, emergency lights and sirens
Will they respond to their name?
When approached by police will there be fight or flight?
Repetative Behavior?
Impaired sense of danger?
Speech Delay?
Favorite color, tv shows, water, etc.
Senstive to light, loud noises, crowds etc.

Safe Person/Emergency Contact Information

Safe Person 1: Name
Safe Person 1: Address
Safe Person 2: Name
Safe Person 2: Address

Frequently Asked Questions

How is this information used?

The information will be stored in the Police Department’s records system. If/when there is a call for service, the dispatching officer will inform the responding officer/s if there is a North Reading Person with Disability Form submitted for the party. The knowledge of this information will provide the first responders with awareness of how to engage the individual using best practices.

Who is this information shared with?

The information that is shared with the Police Department will be kept in the department’s in-house record system. When there is a call for service, the dispatching and responding officers will have access to this information. This information can be shared with the Fire Department if they are responding to the call as well.

How often should this information be updated?

This form should be updated at least annually, or more frequently if there are significant changes to the individual, including but not limited to: appearance, preferences, or behaviors.

How can I receive more information regarding this form?

More information can be found by calling the Police Department’s non-emergency line: (978) 664-3131.