911 CENTER Computer aid Dispatch (CAD) INFORMATION SHEET
NAME
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER
TYPE OF HANDICAP/DISABILITY/SPECIAL NEEDS
DO YOU HAVE TDD (TELECOMMUNICATIONS DEVICE FOR THE DEAF) CAPABILITY OR ARE
YOU UTILIZING AN OUTSIDE SERVICE TO CALL 911?
______________________________________________________________________
IS OXYGEN USED IN THE HOME? __________IF YES, LOCATION:
WHAT IS YOUR DOCTORS NAME?
WHICH HOSPITAL DO YOU PREFER?
SUBMIT ANY SPECIAL INSTRUCTIONS/INFORMATION YOU MAY WANT 911 AND/OR
RESPONDERS TO KNOW:
________
________________________________________________________________
LIST ALL EMERGENCY CONTACT NAMES & NUMBERS:
RELATIONSHIP
TELEPHONE NUMBER
RELATIONSHIP
TELEPHONE NUMBER
RELATIONSHIP
TELEPHONE NUMBER
RELATIONSHIP
TELEPHONE NUMBER
SIGNATURE
DATE
(PERSON FILLING REQUEST OUT)
RETURN THIS FORM TO: NEW HANOVER COUNTY 911 COMMUNICATIONS
230 GOVERNMENT CENTER DRIVE, SUITE 185
WILMINGTON, NC 28403
ATTENTION: DEBORA COTTLE
OFFICE PHONE: 798-6931 / OFFICE FAX 798-6925
Please call or fax the above numbers with any corrections, deletions or additional information.
Revised 6/19/13