State Of Delaware 911 Emergency Information
This information is confidential. It is for use by 911 centers only.
Print this form out, complete and send to: State of Delaware 911 Administration - 165 Brick Store Landing Road - Smyrna, De 19971 or fax to: (302) 659-6856. For questions, please call (302) 659-2349
Page 1
County: ___New Castle ___Kent ___Sussex
This is the telephone number from which an emergency call might come:
(302)_____________________________________ This is ___Voice ___TTY ___Both
(302)_____________________________________ This is ___Voice ___TTY ___Both
Street Address:___________________________________________________________________________________________
City:______________________________________________________ State:DE Zip:______________________________
These are the people in this residence who may need assistance:
Person #1: ___ Male ___Female Date of Birth:_______________________
___Deaf/Hard of Hearing ___Blind/Visually Impaired ___Uses Wheelchair ___Confined to Bed
___Uses Crutches/Walker/Braces ___Mental Retardation ___Cardiac Condition ___Mental Illness
___Epilepsy ___Chronically Obese ___ Speech Impairment Other:__________________
If situation is temporary, when will this information no longer be true?_________________________________________________
Person #2: ___ Male ___Female Date of Birth:_______________________
___Deaf/Hard of Hearing ___Blind/Visually Impaired ___Uses Wheelchair ___Confined to Bed
___Uses Crutches/Walker/Braces ___Mental Retardation ___Cardiac Condition ___Mental Illness
___Epilepsy ___Chronically Obese ___ Speech Impairment Other:__________________
If situation is temporary, when will this information no longer be true?_________________________________________________
This residence has: ___Doorbell Flasher ___Service Dog ___Oxygen Tank ___Guard Dog ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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If a resident is confined to bed or otherwise immobile, this is the room in the home where the person is generally located (please describe): _________________________________________________________________________________________
If some residents in the home use a language other than English, please list here:____________________________________
Additional Information about this residence, the people in it, alternative communication devices that might be used or potential hazards that emergency responders might need to know:__________________________________________________________________
_______________________________________________________________________________________________________
Person responsible for filling out this form:
Name:______________________________ Agency (if applicable):_________________________________________________
Address:________________________________________________________________________________________________
City:________________________________ State:______ Zip:_____________________
Telephone: _____________________________________ This is ___Voice ___TTY ___Both
_____________________________________ This is ___Voice ___TTY ___Both
Signature:______________________________________ Date:_______________________
The signature is the ___Individual ___Parent ___Guardian ___Other:____________________