M I LFORD (Massachusetts)
9-1-1 DISABILITY INDICATOR FORM –
Individual Record
The filing of this document with the Milford (Massachusetts)
9-1-1 Municipal Coordinator will alert public safety officials that an
individual residing at your address in Milford (Massachusetts) 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.
Telephone Number: Area Code ( _____ ) ___________________ 
Voice
TTY
Name: (PRINT CAREFULLY_________________________________________________
Address: (PRINT CAREFULLY)_______________________________ ,
Milford, MA 01757
The following are approved designations for inclusion in the
Milford Massachusetts 9-1-1 Database to assist public safety dispatchers in
responding to an emergency at your address:
Any changes should be
promptly communicated to the Milford (MA) 9-1-1 Municipal Coordinator.
“LSS” Life
Support System: Alerts the public safety dispatcher that someone at
that address is linked to equipment required to sustain their life.
“M I” Mobility
Impaired: Alerts the public safety dispatcher that someone at
that address is bedridden, uses a wheelchair or has another mobility impairment.
“B” Blind:
Alerts the public safety dispatcher that someone at that address is legally
blind.
“D H H”
Deaf and Hard of Hearing: Alerts the public safety dispatcher that someone at
that address is deaf or hard of hearing.
“T T Y” Teletypewriter:
Alerts the public safety dispatcher that communication
via the telephone with someone at that address may be by TTY.
“S I” Speech
Impaired: Alerts the public safety dispatcher that someone at
that address is speech impaired.
“C I” Cognitive Impairment: Alerts the public safety dispatcher that someone at
that address has some degree of cognitive disability.
PLEASE REMOVE
any designation presently displayed.
PLEASE CHANGE
existing designators to those shown above.
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 Statewide Emergency Telecommunications Board (SETB), 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 change or delete the same.
Signed: ____________________________________________
(customer) Date: _____________
Signed: ___________________________________________(Municipal
Coordinator) Date:_________
Print, complete
it according to the instructions, then sign and mail it to your Milford (Massachusetts)
9-1-1 Municipal Coordinator: Mr. Louis J. Celozzi, E911 Coordinator,
Milford Town
Hall, 52 Main Street, Milford, MA 01757